Fig. 2

Technique of rectal amputation with an initial perineal approach. In this patient, conversion from intersphincteric resection to rectal amputation was required because mucinous adenocarcinoma invasion was suspected on the dissected plane between the internal and external anal sphincter muscle (a). At the anterior aspect, we detached both the transverse perineal muscle and the rectourethralis muscle and then dissected along the posterior wall of the prostate to the peritoneal refraction (b and c). At the posterior aspect, we separated the anococcygeal raphe and then cut along the avascular holy plane toward the rectosacral ligament originating from the presacral parietal fascia (d). Finally, the perineal wound was sufficiently irrigated with saline and closed with absorbable sutures. The subcutaneous fat was subsequently reapproximated at the midline with absorbable sutures, and the skin was reapproximated with interrupted monofilament sutures in a vertical mattress fashion (e and f)