Written and medically reviewed by: Assoc. Prof. Cengiz Dibekoğlu, MD, General SurgeryLast updated:
Rectal Cancer — Abdominoperineal Resection (Miles)
Combined removal of rectum and anal canal with permanent end colostomy when sphincters cannot be preserved safely.
Miles’ operation (abdominoperineal resection, APR) removes the rectum and anal canal together without sphincter preservation — the classic operation for selected distal rectal cancers. A permanent end colostomy is created and the perineum is closed. Named after William Ernest Miles, it remains the fundamental option when sphincters are involved or sphincter-preserving surgery is not oncologically safe.
Educational schematic. Some structures may be simplified or emphasized for clarity; not an exact anatomical depiction.
© Cengiz Dibekoğlu — illustrative; not for unauthorized use
Figure summary
- This educational figure shows: Abdominoperineal resection (Miles).
- Related figures on this page: TME plane.
Related educational figures
Tap a figure to enlarge.
TME plane Educational schematic. Some structures may be simplified or emphasized for clarity; not an exact anatomical depiction.
© Cengiz Dibekoğlu — illustrative; not for unauthorized use
Figure summary
TME plane
Who may be a candidate?
- Tumors invading anal sphincters or levators
- Very distal tumors where a safe sphincter-preserving margin cannot be taken
- Cases still unsuitable for sphincter preservation after neoadjuvant therapy
- Selected patients with severe baseline incontinence in whom a low anastomosis would worsen quality of life
Possible advantages
- Oncologically appropriate when sphincter invasion or unsafe distal margin precludes LAR / ISR
- Delivers TME plus complete anal-canal clearance as one intact specimen
- Extralevator APR (ELAPE) can be planned in selected advanced distal cases to improve cylindrical specimen / CRM quality
- Clear functional pathway with structured stoma nursing support
Limits & realistic expectations
- Permanent colostomy — lifelong bag care and education
- When sphincter preservation is oncologically and functionally feasible, LAR / ultra-low may be preferred
- Selected complete responders may defer surgery via watch-and-wait instead
- Perineal wound healing can be slow, especially after radiotherapy
Step-by-step overview
- 1
Abdominal entry and exploration
Open, laparoscopic, or robotic entry. Liver and peritoneum are assessed. Left colon is mobilized; IMA/IMV controlled.
- 2
Pelvic TME
Dissection in the mesorectal plane down to the pelvic floor. Anterior urogenital structures and lateral nerves are protected when possible.
- 3
Perineal phase
Circumferential incision around the anus; anal canal, sphincters, and (per plan) levator tissue are resected. Specimens join abdominal dissection and come out intact.
- 4
Permanent colostomy
Proximal colon is matured as an end colostomy, usually in the left lower quadrant. Stoma perfusion and maturation are checked.
- 5
Perineal and abdominal closure
Perineal defect closed primarily or with flap. Hemostasis, drain decision, and wound-care plan.
Key points
Two-field operation
In the abdominal phase, TME mobilizes the rectum in the pelvis; in the perineal phase the anal canal and sphincter complex are removed. The specimen must remain intact as one piece.
Permanent colostomy
There is no anastomosis. An end colostomy is usually sited in the left lower quadrant. Lifelong stoma care is needed; education and stoma-nurse support are critical.
Extralevator APR (ELAPE)
In selected distal / advanced cases, perineal dissection may be planned wider (extralevator) to improve cylindrical specimen and CRM quality. Choice varies by center and stage.
- Key note inside
Perineal wound
The perineum is closed; healing can be difficult, especially after radiotherapy. Flap or specialized closure techniques are used when needed.
After surgery
Stoma education (appliance changes, skin care, diet); perineal wound care; early mobilization and thrombosis prevention; sexual and urinary function follow-up; adjuvant oncology as pathology directs.
- Key note inside
Important
Educational information only — Miles versus sphincter-preserving surgery is decided by MRI, examination, neoadjuvant response, and shared goals — not preference alone.
Frequently asked questions
Is the bag permanent after Miles?
Yes. Standard Miles / APR creates a permanent colostomy. There is no anastomosis and no temporary stoma intended for later closure.
Why is APR still performed?
When sphincters are involved or a safe sphincter-preserving margin cannot be obtained, it may be the correct oncologic choice. Organ preservation is not safe for every distal tumor.
Can LAR / ISR later convert to Miles?
Rarely — severe pelvic complications, local recurrence, or salvage surgery may require APR.
Can daily life continue with a permanent colostomy?
Yes. With stoma-nurse teaching, an appropriate appliance system, and skin care, most people return to work, travel, and suitable exercise. Problems reported early are usually manageable.
Why can the perineal wound heal slowly?
Prior radiotherapy, wide tissue removal, diabetes, smoking, and infection risk can slow healing. Selected patients need flap closure and specialized wound care.
More chapters in this hub
Rectal vs Colon Cancer
Differences from colon — explained for shared decision-making
Total Neoadjuvant Therapy (TNT)
Total neoadjuvant therapy — sequencing chemotherapy and radiation before surgery
Watch-and-Wait for Rectal Cancer
Non-operative management after clinical complete response — with strict surveillance
Rectal Cancer Operations
Operations: what the procedure aims to do and who it fits
Liver Metastases (colorectal)
When rectal cancer involves the liver: sequencing and hybrid liver treatment
Low Anterior Resection (LAR)
Sphincter-preserving resection with TME when tumor height allows
Ultra-Low / Intersphincteric Resection
Very low anastomosis and the function trade-off
LARS After Rectal Surgery
Frequency, urgency, and leakage — diet, medicines, and pelvic rehab
TAMIS Surgery
Natural-orifice transanal local excision — no abdominal incision; single-port robotic TAMIS is a selected setup
TaTME
Selected mid and low rectal cancers: the lowest part is done through the anus, and the surgeon also works through the abdomen — not TAMIS
Recurrent Pelvic Rectal Cancer
Restaging, salvage surgery, and realistic goals after recurrence
Anal Canal Cancer
Squamous anal cancer — distinct from rectal adenocarcinoma; chemoradiation first
Appointment / info
This page is for education. It is not medical advice and does not replace a visit with your physician.
Medical editor: Assoc. Prof. Cengiz Dibekoğlu, MD · Last medically reviewed: August 2026 · English patient-education chapter.