APR should start with a discussion with the patient in the course of which he must be informed of the nature of disease, the need of removal of the rectum and anal sphincter and, if required, the need of resection of vagina wall, adnexa or bladder as well as about the formation of colostomy. Prior to the operation, the patient should be examined by a stomatherapist, which along with the selection of a location for a future stoma must as much as possible adapt the patient to the idea of the possibility of living under modified conditions.
Moreover, it is necessary to perform bowel preparation by means of antegrade lavage with 41 of polyethylene glycol pre-operatively. Until now, the idea of antibacterial preparation of the bowel before operation has not been totally supported.
The two-team approach to APR is preferred. However, the presence of an experienced surgeon-assistant capable of performing the perineal phase of the surgery is an obligatory condition. This will significantly reduce the operative time, enabling surgeons to correct the direction of extraction of the rectum (especially in case of advanced tumours), and facilitate providing the final haemostasis after removal of the specimen. The abdominal team should play the crucial role in extraction of the rectum. In order to proceed with the perineal phase of the operation, it is necessary to complete TME. This is due to the fact that procedures carried out by the perineal team necessarily result in the drift of the rectum in the pelvis area, which prevents the precise extraction of the rectum and the synchronous saving of the autonomic nerves of the pelvis. Moreover, the visceral fascia can be injured. After the TME technique has been developed, the technical difficulties of extraction of the anterior wall of the rectum from the perineal side appear easily surmountable.
After total anaesthesia in combination with a peridural anaesthesia, the patient is placed on the table in a perineolithotomy position. Pneumatic compression devices are fitted to the legs to prevent thromboembolic complications. The perineum of the patient must project over the end of the table. The catheter is inserted into the bladder. Along with urine drainage, this allows attainment of required orientation when the front wall of the rectum in males is extracted. Proctoscopy examination is performed to reassess the rectal cancer and irrigate the rectum until clear. The abdominal and perineum skin (including vagina in females) are prepared in the conventional way.
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