Use of the total mesorectal excision technique (TME) for the abdominal part of an abdominoperineal resection procedure for a very low rectal cancer requires dissection of the mesorectum off the levator ani muscles. This results in the resected specimen having a narrow waist where the mesorectum ends just at the very level of the tumor and hence a risk of a reduced resection margin at this level, which may account for reports of increased local recurrence after abdominoperineal resection when compared to low anterior resection of the rectum. Recent efforts to address this in open surgery have resulted in the recently described “cylinder” operation - a much more extensive perineal dissection of a cylinder of tissue comprising all of the ischiorectal fat and a wider resection of the levator ani muscles from below, usually requiring the patient to be repositioned in the prone position after the abdominal dissection is complete.

This video demonstrates our recent laparoscopic approach in which instead of completing a total mesorectal excision, the mesorectal dissection is stopped as soon as the levators are visualized. The mesorectum thus remains undisturbed from the levators, which are then divided from above under direct laparoscopic vision. The ischiorectal fat is similarly divided and contact can then be made with a perineal operator well below the now divided levator ani muscles at a safe point where the excision margin is not threatened. Division of the levator ani muscles from above results in a more straightforward procedure for the perineal surgeon.

The laparoscope therefore holds the potential for a wider excision of the levator ani muscles under direct vision allowing the production of a cylinder-shaped specimen with wider tumor resection margins during abdominoperineal resection of the rectum.

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