• Colorectal cancer
• fixation
• musclesurgerysurgical pathology

There is a renewed interest in optimising the surgical technique of abdominoperineal resection (APR) to improve outcomes for low rectal cancer. Compared with anterior resection APR is associated with higher rates of intraoperative perforation and circumferential resection margin (CRM) involvement which compromise oncological outcome.1 One suggested refinement is the use of a cylindrical extralevator dissection (extralevator abdominoperineal excision) (extralevator APE). The primary aim of such surgery is to avoid ‘coning down’ or ‘surgical waisting’ as dissection approaches the anal canal from above and below. The extralevator APE technique requires the surgeon to perform a wider resection in this area to include a muscular cuff with an intact external anal sphincter incorporating the levator ani muscle around the anorectal junction. A large multicentre study by West and colleagues recently reported a significant reduction in circumferential margin involvement with the extralevator APE technique when compared with standard APR.2

As the extralevator APE approach is recognised to provide …