Key Concepts

• Local recurrence of rectal cancer is an extra-total mesorectal excision (TME) pathology and differs inherently to advanced primary rectal cancer with respect to treatment planning and management, as well as surgical training.
• Surgery for recurrent rectal cancer requires meticulous planning and is based on magnetic resonance imaging (MRI) and requires multidisciplinary team (MDT) interpretation and collaboration.
• Surgeons embarking on recurrent rectal cancer operations must be adept at resecting the anterior, lateral, and posterior pelvic compartments.
• Circumnavigate the involved pelvic compartment—operate in virgin planes.
• Gain proximal and distal control of organs, vessels, and nerves prior to final resection.
• If recurrence abuts an organ, vessel, nerve, or structure, then resect it, and avoid “close shaves,” which risks an involved margin. R0 resection predicts both survival and quality of life.
• Posteriorly the pelvic floor is the site of recurrence. It arises from the sacrum (S3 down) and the sacrospinous ligament out to the ischial spine and abuts the piriformis muscle laterally and the obturator internus muscle anteriorly.
• When considering surgical anatomy, the ischial spine is the center of the lateral pelvic compartments, while the urethral orifice (as it passes through the pelvic floor) is the center of the anterior compartment.
• En bloc common and external iliac artery and vein excisions can be performed with R0 rates and survival comparable to more central recurrences and with good arterial graft patency but high rates of venous graft thrombosis. Consideration should be given to venous ligation without reconstruction after excision.