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What is Extra-levator Abdominoperineal Excision of the Rectum (ELAPER)?

Extra-levator abdominoperineal excision of the rectum (ELAPER) is a comparatively new surgical technique employed in the treatment of tumours or cancers of the lower rectum or anal canal that infiltrate sphincter muscles. The surgical technique involves the removal of the rectum and anal canal together with the blood supply and connected lymph glands. ELAPER is a much more radical approach than the traditional abdominoperineal excision of the rectum (APER) with improved oncological outcomes.

Indications for Extra-levator Abdominoperineal Excision of the Rectum (ELAPER)?

ELAPER for lower rectal cancer is indicated to prevent the adverse oncological outcomes associated with traditional APER technique such as intra-operative tumour perforation (IOP), high incidence of circumferential resection margin (CRM) involvement, and local recurrence and survival. The ELAPER technique improves oncological outcomes by removing increased tissue in the distal rectum and all together removal of the levator ani muscles thereby reducing IOP, local recurrence, and CRM involvement.

Preparation for Extra-levator Abdominoperineal Excision of the Rectum (ELAPER)

Pre-procedure preparation for ELAPER will involve the following steps:

  • A thorough examination by your doctor is performed to check for any medical issues that need to be addressed prior to surgery.
  • Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
  • You will be asked if you have allergies to medications, anaesthesia, or latex.
  • You should inform your doctor of any medications, vitamins, or supplements that you are taking.
  • You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
  • You should refrain from alcohol or tobacco at least 24 hours prior to surgery.
  • You should not consume any solids or liquids at least 8 hours prior to surgery.
  • You will be placed on a special diet prior to surgery and laxatives may be used to clean out your bowel.
  • You may be instructed to shower with an antibacterial soap the night prior to surgery to help lower your risk of infection after surgery.
  • Arrange for someone to drive you home as you will not be able to drive yourself after surgery.
  • A written consent will be obtained from you after the surgical procedure has been explained in detail.

Procedure for Extra-levator Abdominoperineal Excision of the Rectum (ELAPER)

ELAPER can be performed either as a traditional open surgery with two separate incisions, one through the abdomen and the other around the anus, or as a laparoscopic surgery with multiple small keyhole incisions, under regional or general anaesthesia. Your surgeon will determine the best approach for you based on the severity of your condition. During the surgery, part of the large intestine (bowel) and the rectum are mobilized (released from their surrounding attachments) through the abdomen. The anal canal is then mobilized through an incision around the anus and the diseased part is safely removed including some sections of fatty tissue that carry the lymph drainage and blood vessels to the rectum. Utmost care is taken to prevent any damage to surrounding soft tissue structures during the operation. The large intestine is then brought out through a colostomy. A colostomy is a surgical procedure in which one end of the large intestine is brought out through the abdominal wall by making a small cut in the abdominal wall to create an opening called a stoma. Stools are then passed through the stoma and collected in a pouch attached to the skin. At the end of the procedure, the incisions around the anus and the abdominal wall are closed with absorbable sutures and sterile dressings are applied.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after extra-levator abdominoperineal excision of the rectum (ELAPER) will involve the following steps:

  • You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anaesthetic reactions to the medications and anaesthesia used.
  • You will likely need 4 to 5 days of stay in the hospital after surgery. Your nurse will monitor your blood oxygen level and other vital signs as you recover.
  • You may notice some pain, inflammation, and discomfort in the operated area. Pain and anti-inflammatory medications are provided as needed.
  • Medications may also be prescribed as needed for symptoms associated with anaesthesia, such as vomiting and nausea.
  • Walking and moving around the bed is strongly encouraged as it lowers the risk of blood clots and pneumonia and helps to stimulate your bowels.
  • Antibiotics are prescribed to address the risk of surgery-related infection.
  • It is important to keep the surgical site clean and dry. Instructions on surgical site care, stoma, stool collecting pouch, and bathing will be provided.
  • Refrain from smoking for a specific period of time as it can negatively affect the healing process.
  • Eating a healthy diet rich in low fat and high-fibre and drinking 8 to 10 glasses of water daily is strongly recommended to prevent constipation. Laxatives or stool softeners may also be recommended as needed.
  • Refrain from strenuous activities and lifting anything heavier than 10 pounds for the first couple of months. Gradual increase in activities over a period of time is recommended.
  • You will need to take off work a couple of weeks or longer to rest and promote healing. Walking is a good exercise and is strongly recommended to improve your endurance.
  • Refrain from driving until you are fully fit and receive your doctor’s consent. Most patients often take 2 to 4 weeks to drive.
  • You will be able to resume your normal activities within a couple of weeks, but may have certain activity restrictions.
  • A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Extra-levator abdominoperineal excision of the rectum (ELAPER) is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:

  • Infection
  • Bleeding
  • Hematoma (accumulation of blood in the wound)
  • Seroma (accumulation of clear fluid in the wound)
  • Damage to surrounding soft tissue structures
  • Post-procedure pain, requiring narcotics for relief
  • Blood clots
  • Pneumonia
  • Heart problems
  • Bladder problems
  • Kidney problems
  • Anaesthetic/allergic reactions
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    Robotic surgery programme

  • Directorvinar
  • Advisorkcs
  • Senior Consultant

    Department of Colo-rectal surgery

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    Mortality peer review group

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    Medical Records QA review group

  • Head of colorectal serviceskarnataka
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