Colectomy
Surgery for colon cancer

Surgical principles

The treatment of colon cancer depends on the stage of the disease. Surgery is the main treatment for earlier stage colon cancer. When a surgeon operates for cancer, he removes the cancer-bearing organ or part of it to the healthy tissue along with the adjacent draining lymph nodes. Lymph nodes are small glands that are part of our lymphatic system. They are situated alongside the blood vessels that supply blood to the concerned organ. Lymph nodes play a vital role in our body’s defence system. They filter and trap the cancer cells, preventing them from reaching other organs of our body (metastasis).

Colectomy

Colectomy means surgical removal of the colon. Depending on the disease and stage, either part or whole of the colon is removed. Colectomy is done for diseases affecting the colon and rectum including cancer.

Partial colectomy, hemicolectomy or segmental resection

Partial or segmental colectomy means removal of a segment of the colon.

It's termed hemicolectomy (right or left) when half (approximately) of the colon is removed.

During a colectomy, the surgeon removes the diseased part of the colon with a margin of a healthy colon and draining lymph nodes. Since the lymph nodes are along the blood vessel, the blood vessel is divided at its origin to remove all the draining lymph nodes. The extent of colonic resection depends on the blood supply which is cut. Intestinal continuity is then re-established by joining the cut ends of the intestine (anastomosis).

This surgical procedure has various names depending on the segment of colon resected; right hemicolectomy, left hemicolectomy, sigmoidectomy, transverse colectomy, extended right or left hemicolectomy and anterior resection.

Total colectomy (proctocolectomy) or subtotal colectomy

Sometimes, the whole colon needs to be removed. When only the colon is removed it is termed subtotal colectomy and if the rectum is also removed it is called total colectomy or proctocolectomy.

This procedure is done when multiple polyps, inflammatory bowel disease or dilatation because of intestinal obstruction affects the large intestine.

Ostomy

Occasionally, when the tissues are not healthy and the anastomosis is unlikely to heal. In such cases, an opening of the intestine is made over the abdomen called ostomy (ileostomy or colostomy). This is temporary and is closed after the improvement in patients' condition and chemotherapy (if required).

There are two ways to do a colectomy:

• Open, and
• Laparoscopic or robotic

Open colectomy

In open surgery, we make a single long incision over the abdomen to do the surgery. This was the traditional way of doing the surgery. It resulted in delayed recovery, long hospital stays and nasty scars.

Laparoscopic colectomy

Laparoscopic, minimally invasive, or keyhole surgery is an important innovation that has changed the practice of surgery. It minimizes suffering and improves outcomes. It has now become a standard for most gastrointestinal operations.

In laparoscopic surgery, we make a few small holes called ports over the abdomen. One of them is used to insert a slender high-resolution camera that projects a magnified view of the inside of the abdomen onto a high definition monitor. The rest of the ports are used for long and thin instruments. The surgeon deftly manoeuvres the instruments looking at the monitor.

Minimally invasive surgery is beneficial for the patient in several ways. Post-operative stress and pain are markedly reduced, leading to a faster recovery and shortened hospital/ICU stay. The amount of blood loss in the process of surgery has decreased. There is a quicker return of intestinal movement. The overall complication rate is decreased. All this results in an earlier return to home and work. The absence of a long scar is pleasant to the eyes.

Robotic colectomy

Robotic surgery combines the skill and expertise of a surgeon with the vision, precision, and flexibility of robotic technology. The robotic system features a 3D high-definition camera system for clear and enhanced vision with depth perception. It comprises a surgical console, where the surgeon sits, and robotic arms equipped with surgical instruments. The tiny wristed instruments can bend and rotate in ways the human hand cannot, allowing the surgeon to operate in tight spaces.

During robotic surgery, the surgeon makes minor cuts in the abdomen and inserts special tubes called ports. The robotic arms are connected to these ports, and the instruments mounted on these robotic arms go through the ports to do the surgery. A slender camera is also inserted through one port to show the surgeon a clear view of the inside. The surgeon controls the robotic arms from a console nearby, and an assistant helps by changing the instruments and aiding as needed.

Proven with research

In the United States, the COST study group was formed to study laparoscopic surgery for colon cancer. In Europe, it was tested in the COLOR trial and the United Kingdom by researchers of the CLASSIC trial. These researchers concluded that the chances of getting rid of cancer with laparoscopic surgery were as good as open surgery. The patients undergoing laparoscopic surgery had less blood loss, shorter hospital stay and fewer pain medication requirements.

Colon cancer and intestinal obstruction

Cancer will sometimes block the colon, a condition called intestinal obstruction. In such cases, a stent may be placed to relieve the obstruction, improve the condition of the patient and then do the surgery. Or, surgery is done to remove the tumour. In such cases, usually, the ends of the intestine are not reconnected but brought out as stoma. the ends of the intestine are reconnected later in a second operation when the health of the patient improves.

Treatment of advanced (stage 4) colon cancer

Many colon cancer patients will have stage 4 cancer at the time of presentation. Stage 4 cancer means that colon cancer has spread to other organs of the body.

Surgery - curative

Some stage IV cancers have spread limited to few spots of cancer in the lung, liver and peritoneum. If cancer in the colon and all these spots can be safely removed, then surgery can attempt to cure the disease.

Liver resection

It is a surgical procedure to remove cancer containing part of the liver, also called hepatectomy or metastasectomy.

Lung resection

Pulmonary (lung) resection is a surgical procedure to remove the part of the lung, which has cancer.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC)

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) treats colorectal cancers that have a limited spread to the abdominal cavity (peritoneum). During cytoreductive surgery, all visible tumours are surgically removed, which only leaves microscopic cancer cells. Cytoreductive surgery is followed by HIPEC, which aims to destroy the remaining microscopic cancer cells. In HIPEC, concentrated and heated chemotherapy solution is delivered directly into the abdominal cavity, which kills those cells.

This approach helps the patients live longer and provides them with a chance to be free of cancer over the long term. We prefer to give neoadjuvant treatment before surgery in these patients.

Surgery - Palliative

Ostomy (ileostomy or colostomy) is an operation to make an opening in the intestine and bring it out by creating a hole in the abdomen's wall. It excretes stool into a bag that fits securely over the opening. The surgeon does an ostomy when the tumour has grown too big and causes intestinal obstruction (blockage) while the patient is unfit to undergo major surgery to remove the tumour or cancer has spread to other parts of the body.

Risks (complications) of colectomy

All surgeries can be associated with complications and so is the case with colon cancer surgery. Some of the common possible complications after colon cancer surgery include:

• Anastomotic leak: the joint of the intestine can leak.
• Infections - surgical site, pulmonary: Infections can occur after the surgery.
• Cardiac complication: Heart-related complications
• Bleeding: There can be bleeding during or after surgery
• Injury to adjacent organs: Many internal organs are very close to the colon. They can be injured during surgery.
• Anaesthesia related complications: There can be complications related to the administration of anaesthesia and recovery.
• Postoperative obstruction: Post-surgery intestines can stop working, a condition known as postoperative ileus. They can get stuck or entangled requiring surgery.
• Deep venous thrombosis: Clots can form in the veins of the leg due to immobility. These clots can travel to the lung also.
• Hernia: Hernia can form at the incision site.

Before surgery

Following steps will be taken to ensure the best outcome.

• Tests related to diagnosis, staging and surgical planning
• Tests related to fitness for surgery
• Optimising coexisting illness: Those with pre-existing illnesses such as diabetes, hypertension, cardiac disease etc. will be optimised to the best possible health.
• Admission and bowel preparation: Some patients will be given medicine to empty the colon before the surgery.

Can read more about preparing for surgery here.

After surgery

You will be closely monitored while you recover. It generally goes through the following steps.

• Intensive monitoring: Monitoring takes place in the ICU or recovery room
• Removal of tubes (Nasogastric, Foley and drain): Few tubes are placed during the surgery to facilitate the recovery. They are removed sequentially.
• Start and increase the diet: The oral intake is started with clear fluids and increased to a liquid diet and soft diet over a few days.
• Discharge: Once you are fully mobile and oral intake is adequate you will be discharged with instructions to follow at home. This usually happens 4-6 days after surgery.
• Follow up: Follow up visit is planned a week or 10 days after discharge. Clips or stitches over the incision are removed. The final biopsy report and further treatment plans are discussed.

Stay Alert! Stay Healthy!
Wish you a speedy recovery!