Extralevator abdominoperineal excision

Extralevator abdominoperineal excision (ELAPE) has been introduced to alleviate the disappointing results of conventional abdominoperineal excision (APE) with respect to inadvertent bowel perforation, positive circumferential resection margins (CRM), and local recurrence rates. The main principle of this operation is to shift the resection plane away from the anorectal junction, which is the area at highest risk of perforation and CRM positivity. This is accomplished by resection of the levator ani muscle, which is followed at its outer surface close to its origin at the pelvic side wall. The anterior region is also addressed with comfortable access to the dissection area by placement of the patient in prone jackknife position. All measures aim to avoid a waist at the anorectal junction. This article describes the procedure in detail, including strategies to close the perineal defect. In a brief review of the literature, the favorable results of ELAPE are discussed. Conclusion. It can be concluded that the perineal phase of ELAPE is highly standardized and can be taught in a step-by-step fashion. There is evidence that ELAPE results in lower rates of inadvertent bowel perforations, lower rates of positive CRM, and lower rates of local recurrence.