title: The combined abdominal and perineal approach for dissection of the lower rectum. The development of new indications.
abstract: OBJECTIVE
  Dissection of the lower rectum in some low rectal and pararectal pathologies can be technically difficult that it ends up in abandoning the procedure or raising a permanent stoma. The recently described combined abdomino-perineal approach allows completion of rectal dissection from the perineal route and preservation of the anal sphincters. Patients requiring the combined approach are not seen frequently and reports on this new technique are scarce. The purpose of this study is to analyze our results of using the combined abdomino-perineal approach in different benign and malignant low rectal pathologies, and to describe two new indications for the technique.
  
  
  METHODS
  This is a retrospective analysis of prospectively collected data of 10 patients (8 males, age range 22-75 years), including 7 cancer patients who required the combined abdomino-perineal approach for completion of their procedures. Previously unreported indications for the technique included iatrogenic rectovaginal fistula and presacral tumor. The study was conducted in a tertiary referral colorectal unit in a university hospital.
  
  
  RESULTS
  The procedure was completed and the sphincters preserved in all patients. All cancer patients had adequate resection with good quality mesorectum. Continence was preserved in 4 patients. Three patients are living with permanent stoma. Anastomotic perineal fistula requiring dismantling the anastomosis and raising a permanent stoma occurred in one patient.
  
  
  CONCLUSIONS
  The combined abdomino-perineal approach is useful to complete rectal resection in a highly selected group of patients with technically difficult low rectal pathologies. The technique is probably safe in cancer patients and new indications are evolving. Expectations for preservation of continence are disappointing.
authors.affiliation: Ain Shams University, Cairo, Egypt.
authors.forename: Ahmed A
authors.initials: AA
authors.lastname: Abou-Zeid
authors.affiliation: Ain Shams University, Cairo, Egypt. Electronic address: yassermohamed.eg84@yahoo.com.
authors.forename: Yasser El
authors.initials: YE
authors.lastname: Ghamrini
authors.affiliation: Ain Shams University, Cairo, Egypt.
authors.forename: Tarek
authors.initials: T
authors.lastname: Youssef
mesh_terms: D000005:Abdomen / Q000601:surgery; D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000601:surgery; D013505:Digestive System Surgical Procedures / Q000379:methods*; D004210:Dissection / Q000379:methods; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D010502:Perineum / Q000601:surgery; D012004:Rectal Neoplasms / Q000601:surgery; D012007:Rectum / Q000601:surgery*; D012189:Retrospective Studies; D055815:Young Adult
keywords: Continence; Lower rectum; Sphincter preservation; Stoma