Surgery for Rectal Cancer

Local resection

Transanal excision, Transanal endoscopic microsurgery (TEM), Endoscopic submucosal dissection (ESD), Transanal minimally invasive surgery (TAMIS)

Very early cancer that is limited to the inner layer of the rectum without lymph nodal involvement can be removed with these approaches. In these techniques, the tumour is approached and resected by instruments inserted through the anal opening.

Anterior resection and low anterior resection

For upper and middle rectal cancers, the tumour-bearing part of the rectum is removed with a healthy margin and lymph nodes. The colon is then reattached to the remaining rectum. The rectum is wrapped in a tissue called the mesorectum. It is important to include it in the resection, a technique called total mesorectal excision (TME).

Rectal cancer surgery | Low anterior resection

Ultra-low anterior resection, Intersphincteric resection

These operations are done for tumours involving the lowest part of the rectum, just above the anal canal (or, part of the inner layer of the anal sphincter). In these operations, the entire rectum is removed and the colon is attached to the upper part of the anal canal. Sometimes the inner layer of the anal sphincter is also partially removed, called intersphincteric resection.

Rectal cancer surgery | Ultra-low anterior resection

Abdominoperineal resection (APR)

When cancers of the lower rectum involve the muscles of the anal canal (anal sphincters), the anal canal needs excision. As the anus is removed, a permanent colostomy is created.

Rectal cancer surgery | Abdominoperineal resection

Pelvic exenteration

Some rectal cancer grows into nearby organs. This includes the urinary system in front of the rectum. The surgery in such cases will also remove part of the urinary system. This procedure is called pelvic exenteration.

Total colectomy (proctocolectomy)

Sometimes, the whole colon needs to be removed along with the rectum. 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.

There are two ways to do rectal cancer surgery:

• Open
• Minimally Invasive (laparoscopic or robotic)

Open surgery

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.

Minimally invasive rectal cancer surgery

Laparoscopic rectal cancer surgery

Laparoscopic, or keyhole surgery 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.

Robotic rectal cancer surgery

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.

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.

Rectal cancer and intestinal obstruction

Cancer will sometimes block the rectum, a condition called intestinal obstruction. In such cases, a colostomy is made before starting the radiotherapy and chemotherapy. In some cases and in those where curative surgery is not an option, a stent can be placed to relieve the obstruction.

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.

All surgeries can be associated with complications and so is the case with rectal cancer surgery. Some common possible complications after rectal 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 and rectum. They can be injured during surgery. This can affect urinary and sexual function.
• 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.
• Increased stool frequency

Before surgery

The 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: A 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.