Posterior approaches

Uses and advantages

Limitations and disadvantages

Perineal

Good exposition of distal presacral space

For lesions deeper and higher compared to an intersphincteric approach

Preservation of coccyx with less postoperative pain

Preservation of sphincter function

Only for low-lying lesions

Limited visualization of possible cranial extension

Transsacral

Best exposition of the presacral space

For lesions higher compared a perineal approach

Less recurrence compared to a perineal approach

Preservation of sphincter function

Resection of mid-rectal lesions in carefully selected patients

No visualization of pelvic vessels: risk of bleeding

Risk of posterior discomfort

Risk of wound dehiscence

Risk of fistula formation

Risk of sacral nerve injury

Transsphincteric

Good exposition of the mid rectal lumen

Useful in case of extension into the rectal wall

Avoidance of sacral nerve injury

Only for low-lying lesions

Risk of sphincter dysfunction

Risk of fecal fistula formation

Intersphincteric

Avoidance of sacral nerve injury

Preservation of sphincter function

Only for very low-lying lesions

Contra-indication in case of preoperative suspicion of malignancy

Transanal/rectal

Useful in case of transrectal ruptured cysts

Useful for rectal polyps

First choice in local treatment of early rectal cancer for carefully selected patients

Limited visualization of presacral space

Risk of incomplete resection (cystic lesions)

Risk of bleeding

Risk of fecal incontinence

Special material

Technical experience

Transvaginal

Useful in cases that deviate from the midline

Only for prerectal lesions

Risk of rectovaginal fistula formation

Risk of dyspareunia