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 |