Optimizing Rectal Cancer Surgery by Total Mesorectal Excision and "Cylindrical" Extralevator Techniques for Abdominoperineal Excision

Since total mesorectal excision for rectal cancer was first described in 1988, widespread adoption of this technique has improved oncologic outcomes signifi cantly. However, improved survival and decreased local recurrence rates in patients having anterior resection have not translated into equivalent improvements in those having abdominoperineal excision and permanent stoma. The most signifi cant factor in determining appropriate first-line treatment is accurate and reproducible prediction of a negative circumferential resection margin. MRI is quickly emerging as the gold standard for the preoperative staging of rectal cancer. It may be the key to assessing whether safe restorative resection is feasible or an abdominoperineal excision may be oncologically superior when performed in a more radical or cylindrical (extralevator) plane. This article explores the latest evidence for optimizing surgery in rectal cancer.