Anatomical considerations of abdominosacral amputation of the rectum (ASAR) in lower-rectal cancer patients

Our experience in the therapy of low-rectal cancers suggests that a marked improvement of outcomes is related to the application of abdominosacral amputation of the rectum (ASAR). The purpose of this short review is to present the anatomical relationships of the lower rectum with special attention given to those structures important for the proper performance of ASAR. The anatomical clues to the successful outcome of ASAR include:
1) prone jackknife position,
2) dissection of a coccyx or S4-5 – if necessary,
3) careful dissection of Waldeyer’s fascia,
4) total resection of the anococcygeal ligament, anal levators and sphincters, and all tissues of the infra-levator compartment which are important for isolated recurrence formation,
5) proper identification and preservation of autonomic nerves and plexuses surrounding the mesorectum,
6) optimal dressing of the surgical wound.
The therapeutic results reported in our previous studies and the herein described anatomical considerations suggest that ASAR may be successfully applied in low-rectal cancer patients as an alternative to the routinely performed abdominoperineal resection (APR).