Abdomino-Perineal Excision of the rectum (sometimes referred to as an AP excision, APE, APR or APER or Extra Levator APER) is an operation that removes the entire rectum and the anal canal. The rectum is the storage organ at the end of the bowel and the anal canal is the exit from the bowel (the 'back passage'). This will mean the formation of a permanent colostomy (stoma) for bowel emptying into a bag attached to the abdominal wall.
Diagram of colon & rectum showing
part of bowel excised in the operation
|End colostomy as seen at the end of the operation|
The operation is performed via an abdominal incision (either with keyhole surgery or open surgery), and then an incision around the anus. After the operation you will have a scar and a stoma on your abdomen and a scar between your buttocks where the anus has been removed. It is possible in some cases to do the abdominal part of the operation with laparoscopic (keyhole) surgery (see LCS leaflet), but the part of the operation around the anus has to be done as a conventional open operation. Doing the operation this way has the advantage of only tiny scars plus the stoma on the abdomen as the excised specimen is removed through the incision around the anus.
More recently, an extended approach to clear more tissue from the pelvis (and hence reduce the risk of local recurrence) called the Extra-Levator APER has been i use in the United Kingdom. No difference in scars or recovery are seen with this approach, but there is good evidence of reduced local recurrence rates. The operation is technically more demanding and not all colorectal surgeons are trained in the technique. This is being addressed with the LOREC programme.
You will meet a stoma care nurse before your operation to discuss living with a colostomy. This can either be arranged either at the hospital or in some cases the stoma nurse will visit you in your home.
How long does the operation take?
This is very variable and depends on a number of factors. On average the operation will take somewhere between 2 and 3 hours. You will probably be asleep for between 2 and 3 times the duration of the operation. Depending on how quickly you recover and how well you adapt to managing your stoma bag you are likely to remain in hospital for 5-10 days.
What happens after I wake up?
Whilst you are asleep the anaesthetist and surgeon will have placed a number of tubes into you for both monitoring sand treatment. Your are likely to have plastic needles in your arms and possibly one in the side of your neck connected to bags of fluid and very occasionally a blood transfusion . If you elected to have an epidural for post-operative pain control then you will also have a very fine plastic tube in your back connected to a pump that delivers the pain relieving medication. You will also have a catheter in your bladder and possibly 1 or 2 tubes coming from the abdominal wall and around where the anus used to be. You may also have a tube in your nose.
You will have a dressing(s) on your abdomen and a dressing on your bottom. The dressings are often much larger than the wound they are covering especially if you had the abdominal part of your operation performed with laparoscopic surgery. Very occasionally the wound around where the anus used to be has to be left open for a period of time and special dressings are used to pack the area.
You will have a clear bag over your colostomy and this is likely to look rather red and swollen at first, but it will settle down very quickly.
We will aim for you to be as pain free as possible. Some discomfort is to be expected. Sitting up will be particularly difficult at first. Painkillers will usually be given continuously via a pump either into your back as an epidural or your arm as a PCA during the first few days after your operation. Please discuss with your nurse if you feel that your pain is not well controlled.
You will be allowed to drink as soon as you feel up to it and will be allowed a soft diet within 24-hours of your operation. Please see the leaflet on enhanced recovery for more details about this.
What happens when I go home
You will have been taught how to be proficient with your stoma bag by the stoma and ward nurses before you are discharged. You will also be visited by the stoma nurse after discharge to ensure you have no problems. To start with your bowel actions into the stoma bag are very likely to be loose, frequent and unpredictable. This should settle down with time. Most stomas develop a predictable pattern of action, but this may take several weeks or even months to stabilise.
You will either have tiny metal clips or sutures in the skin wounds on the abdomen. These are removed 7-10 days after surgery so will likely be removed after you are discharged. There will be stitches in the wound between the buttocks and these are usually left in for 3-weeks and removed by the stoma care nurse.
You will not be discharged until you are fit to go home. This does not mean that you will be back to your pre-operative level of fitness and comfort by the time of discharge. You will however be able to care for yourself and you will be comfortable. Expect to feel tired in the first few weeks following surgery. For more specific information on this please see the leaflet 'You and Your Bowel Operation'.
Are there any long-term effects after this operation?
Some people find that this operation has some effects on sexual function. In men there can be difficulty with achieving and/or maintaining an erection. This may be temporary or permanent and may also improve with time. It is caused either by bruising around the nerves in the pelvis during the operation or subsequent healing and may also be made worse by radiotherapy if you need to have this prior to surgery.
In women it is sometimes necessary to remove the back of the vagina as part of the operation. It is important for women to ask their surgeon when it will be okay to resume sexual activity. Some women find that the shape of the vagina feels different and that they are dry. Experimenting with different positions for intercourse, the use of lubricants and in some cases hormonal creams may help.
Try not to feel embarrassed about discussing any problems with your surgeon, stoma care nurse or GP as there are often many ways to improve the situation.