Abdominoperineal resection

Abdominoperineal resection

Anesthesia type	General
Airway	ETT
Lines and access	PIVs, consider arterial line
Monitors	Standard +/- arterial line
Primary anesthetic considerations
Preoperative	Consider epidural analgesia
Intraoperative	Blood loss, positioning
Postoperative	PONV, analgesia
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Editor rating	Unrated
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An abdominoperineal resection (APR) is a colorectal surgery that includes the resection of the sigmoid colon, rectum, and anus with construction of a permanent end colostomy. The procedure can be performed robotically/laparoscopically or open.

Overview

Indications

●Crohn proctitis with anal disease

●Ulcerative colitis, not a candidate or amenable to an ileal pouch anal anastomosis

●Fecal incontinence, not amenable to sphincter-sparing procedures

●Low-lying rectal cancer involving anal sphincter complex and/or positive distal margin

●Anal cancer, failed neoadjuvant therapy

●Anal cancer, recurrent

●Anal melanoma

Surgical procedure

Exploration for respectability, mobilization of colon, mobilization of rectum, colostomy construction, omental flap, repositioning for perineal resection, perineal resection, perineal wound closure

Preoperative management

Patient evaluation

System	Considerations
Neurologic	Consider epidural analgesia vs regional anesthesia for open approach
Cardiovascular	Careful attention to fluid management with open abdomen especially if patient received a bowel prep
Gastrointestinal	Assess for nausea and vomiting prior to induction
Hematologic	Type and screen Potential for anemia of chronic disease Obtain platelet count if planning on epidural
Renal	Consider prerenal injury from bowel prep especially if patient already has decreased PO intake in the setting of malignancy

Operating room setup

• Standard OR preparation
• Fluid warmer and Bair hugger
• OG vs NG tube

Patient preparation and premedication

• Patients often have bowel prep
  • Patients typically dehydrated and may have electrolyte abnormalities
• Consider pre-loading patients that are hypovolemic
• Presurgical ERAS protocol

Regional and neuraxial techniques

• Consider preoperative epidural placement for open approach vs regional anesthesia

Intraoperative management

Monitoring and access

• Standard ASA monitors
• 5-lead EKG
• Urinary catheter
• 2 peripheral IVs, at least one large bore
• Consider arterial line

Induction and airway management

• Standard induction and intubation
• Consider need for RSI if patient endorses nausea or vomiting

Positioning

• Emphasis on careful patient positioning given length of procedure
• Positioning typically begins in modified dorsal lithotomy with adequate padding to prevent common peroneal nerve injury
• After completion of the abdominal portion, the perineal portion can typically be completed while still in the lithotomy position with repositioning of the legs. Prone jackknife position may be requested depending on the surgeon.

Maintenance and surgical considerations

• Standard maintenance with either inhalational agent or TIVA
• Consider short acting opioids to minimize the risk of postoperative ileus if no epidural was placed
• Operative time will be prolonged if plastic surgery is required for a perineal flap

Emergence

• Standard emergence and extubation strategies with patient awake and able to protect airway
• PONV prophylaxis

Postoperative management

Disposition

• Patients are typically able to go to the PACU followed by a floor bed after recovery. Consider an ICU disposition for patient comorbidities, significant intraoperative blood loss and resuscitation.

Pain management

• Epidural analgesia if placed preoperatively
• Consider non-opiate adjuncts
• Multi-modal pain management
• May have APS consult if uncontrolled pain or ERAS protocol depending on surgeon

Potential complications

• Hemorrhage
• Anastomotic leak leading to sepsis/septic shock
• High risk for VTE
• Compartment syndrome if legs remain down for a prolonged time with significant fluid/blood resuscitation
• PONV

Procedure variants

	Open	Laparoscopic/Robotic
Unique considerations	More insensible losses/fluid shifts More painful
Position	Supine, lithotomy, possible prone for pelvic portion	Supine, lithotomy, possible prone for pelvic portion
Surgical time	6-12 hours	6-12 hours
EBL	100-500ml	<100ml
Postoperative disposition	PACU	PACU
Pain management	Multimodal analgesia, epidural anesthesia, PCA, regional	Multimodal analgesia, opioids, regional
Potential complications	Hemorrhage, VTE, hypovolemia, PONV	Possible difficulty ventilating during insufflation

References

1. "UpToDate". www.uptodate.com. Retrieved 2026-04-18.