Table 2 Summary of the current trends in surgical procedures for low rectal cancers

Abdomino perineal resection (APR)

Sigmoid, rectum, and anus are excised sparing the levator ani muscles complex (hourglass-like specimen)

Lesions at the lower third of the rectum

Poor oncologic outcome, permanent colostomy

Hussain et al. [8]

Extralevator abdomino-perineal excision (ELAPE)

APR + excision of the levator ani muscles complex (cylindrical specimen)

Lesions at the lower third of the rectum

Permanent colostomy

Carpelan et al. [17]

Intersphicteric resection (ISR)

Surgical plane in the intersphicteric space, dissection of the internal anal sphincter, saving the external sphincter

• Lesions at the lower third of the rectum that do not involve the levator ani muscles

• Good pre-operative sphincter function and continence

May not be suitable for patients that have undergone neoadjuvant treatment

Schiessel et al. [4]

Subtotal intersphincteric resection/partial external sphincteric resection

ISR + partial external anal sphincter resection

• Lesions of the lower third of the rectum invading part of the external anal sphincter

• Good pre-operative sphincter function and continence

Not applicable for lesions invading the levator ani muscle

Mukai et al. [10]

Hemilevator excision (HLE)

Resection of the levator ani muscle, the deep part of external anal sphincter and the internal sphincter ipsilaterally. The contralateral ones are preserved

• Lesions at the lower third of the rectum involving the levator ani muscle in one side

• Good pre-operative sphincter function and continence

Not applicable for cancers circumferentially infiltrating levator ani complex

Noh et al. [11]