1. Positioning and technique of a wide perineal resection ESO-ESSO Master Class in Colorectal Cancer Surgery 12 – 17 February 2011 Cascais, Portugal Torbjörn Holm MD PhD Section of Coloproctology Department of Surgery Karolinska University Hospital Stockholm, Sweden

3. APR in rectal cancer Sir Ernest Miles (1869-1947) Lancet 1908

4. Miles’ Perineal Dissection

5. APER (Miles)

6. Copyright ©2008 BMJ Publishing Group Ltd. Morris, E et al. Gut 2008;57:1690-1697 Problems associated with conventional APR Variation in the use of rectal operations by English NHS hospital trust

9. Conventional APR - synchronous combined

12. Norwegian Rectal Cancer Group Br J Surg 2004; 91: 210-16

14. Problems associated with conventional APR Data from the Dutch TME Trial Local recurrence Survival APR CRM + 30 % 38 % CRM - 9 % 72 % Nagtegaal et al. J Clin Oncol 23; 9257 – 9264, 2005

15. Abdominoperineal Resection Conventional APR Abandon Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus

17. Inter-sphincteric APR Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus

18. Extra levator APR Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus

19. Ischio-anal APR Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus

23. CONCLUSION : Surgical alternatives to Hartmann’s procedure should be considered when the level of transsection is <2 cm above the pelvic floor, particularly in males.

27. Tumour threatening CRM Threatened CRM

35. Tumour perforating into ischio-anal fossa

37. Supine versus prone? Risk of inadvertent perforation West et al. BJS 2010; 97: 588–599

39. Operating table

40. Warmcloud mattress

42. Stoma, drain and catheter (suprapubic)

44. Mobilizer

45. Moving the patient to the prone Jack-knife position with a mobilizer

46. Operating table for prone position Chest and abdomen cushions from TEMPUR company

47. Facepillow From the MIZUHOSI company; 7” gentle touch pillow

49. Patient in the Jack-knife position

51. Colorectal surgery at Karolinska Institutet Workshop and Symposium May 4-6, 2011 Stockholm, Sweden Welcome