Surgery for bowel cancer

Different surgical methods may be used for bowel cancer. Each method has advantages in particular situations – your doctor will advise which method is most suitable for you.

Open surgery Involves one long cut (incision) down your abdomen. Usually means a larger wound and slower recovery. Requires a longer hospital stay. Well-established technique; widely available in Australia. The blue line shows the length and direction of the cut.

Minimally invasive surgery Also called keyhole surgery or laparoscopic surgery. Involves several small cuts. Usually less pain and scarring, a shorter hospital stay and faster recovery. Laparoscope (thin tube with a light and camera) is passed through a cut in the abdomen. Long, thin instruments are inserted through other small cuts. In robot-assisted surgery, a type of laparoscopic surgery, instruments are controlled using robotic arms. The blue dots show the size and position of the cuts.

The most common type of surgery is called a colectomy. There are different types of colectomies depending on whether part or all of the colon is removed. Lymph nodes near the colon and some normal bowel around the cancer will also be removed.

The surgeon usually cuts the colon on either side of the cancer and then joins the two ends of the colon back together. This join is called an anastomosis.

Sometimes one end of the bowel is brought through an opening made in your abdomen and stitched onto the skin. This procedure is called a colostomy (if made from the colon in the large bowel) or ileostomy (if made from the ileum in the small bowel). The opening – called a stoma – allows faecal waste to be removed from the body and collected into a bag.

The stoma is usually temporary, and the operation is reversed later. In some cases, the stoma is permanent. Advances in surgical techniques have led to very few people needing a permanent stoma. Learn more about stomas.

After surgery, you will have a scar. Most people who have open surgery have a scar from above their navel to their pubic area. Here is an illustration of the cut (incision).

Types of colectomies

	Right hemicolectomy The right side of the colon is removed. (If the transverse colon is also removed, it is called an extended right hemicolectomy.)
	Left hemicolectomy The left side of the colon is removed. (If the transverse colon is also removed, it is called an extended right hemicolectomy.)
	Transverse colectomy The middle part of the colon is removed.
	Sigmoid colectomy The sigmoid colon is removed.
	Subtotal or total colectomy Most or all of the bowel is removed.
	Proctocolectomy All of the colon and rectum are removed.

There are different types of operations for cancer in the rectum. The type of operation you have depends on where the cancer is located, whether the bowel can be rejoined, and where in the rectum the join can be made.

You may have an anterior resection or abdominoperineal resection (also known as an abdominoperineal excision). The surgery may be open style or minimally invasive.

Anterior resection – This is the most common operation. This will include creating a temporary stoma, which will be reversed later.

Abdominoperineal resection – This may be recommended if the cancer is near the sphincter muscles or if it is too low to be removed without causing incontinence (accidental loss of urine or faeces) or erection problems. After an abdominoperineal resection you will need a permanent stoma (colostomy). 

Resections in the large bowel

	Abdominoperineal resection or excision (APR or APE)  The sigmoid colon and entire rectum and anus are removed. Your surgeon uses the descending colon to create a permanent stoma (known as a colostomy) for faeces to leave the body. The anal area will be stitched up and permanently closed.
	High anterior resection  The surgeon removes the lower left part of the colon and the upper part of the rectum. Nearby lymph nodes and surrounding fatty tissue are also removed. The lower end of your bowel is rejoined to the top of the rectum.
	Ultra-low anterior resection  The lower left part of the colon and the entire rectum are removed, along with nearby lymph nodes and fatty tissue. The end of the bowel is joined to the lowest part of the rectum, just above the anal canal. In some cases, the surgeon creates a colonic J-pouch (see next diagram).
	Colonic J-pouch   An internal pouch is made from the lining of the large bowel. This J-pouch will be connected to the anus and work as a rectum. You may have a temporary ileostomy (a stoma from the small bowel), which will be reversed once the J-pouch heals.

Transanal endoscopic microsurgery (TEMS) – The surgeon inserts an endoscope into the anus to remove the cancer. TEMS is used for people who have very early stage bowel cancer or are not fit for a major operation may have a local excision. 

Transanal excision (TAE) – If the cancer is very low in the rectum, the surgeon may be able to remove the cancer by passing an instrument up the anus rather than using an endoscope. 

Colonoscopic excision – Can remove small tumours from the colon. This method is less commonly used. 

The type of surgery you have will depend on the location of the cancer. The surgeon will also consider your preferences.

In a small number of people, two separate cancers may be found in the large bowel at the same time. The cancers may be discovered through diagnostic tests or during surgery.

In this case, there are three options for surgery:

1. remove two sections of the bowel
2. remove one larger section of the bowel, containing both areas with the cancer
3. remove the entire colon and rectum (proctocolectomy) to prevent any chance of another cancer forming.

The type of surgery your doctor recommends depends on several factors including the location of the tumours in the colon, genetic and other risk factors, and your preferences.

Sometimes as the bowel cancer grows it completely blocks the bowel. This is called bowel obstruction.

Waste matter cannot pass through the blocked bowel easily, and may cause:

• bloating and abdominal pain
• constipation
• nausea and vomiting.

Sometimes the obstruction is cleared during surgery to remove the cancer. In some cases, the bowel obstruction will mean you have to have emergency surgery. It may be possible to close up the bowel during the surgery, but some people may need a stoma.

Sometimes a stoma is made ‘upstream’ from the obstruction to relieve the blockage to allow time for staging scans of the cancer or chemoradiation before surgery, to make sure the cancer is removed appropriately.

Not everyone with a blockage will want an operation or be fit enough to have it. To help keep the bowel open so that bowel motions can pass through again, your surgeon may be able to put in a small tube (stent).

A stent may also help manage the blockage until you are well enough for an operation. A flexible tube with a light at the end, called an endoscope, is passed through the rectum. This helps the surgeon see the blockage, and the stent is inserted through it.

If you are unable to have surgery or a stent, you may be given medicine to help control the symptoms of a bowel obstruction.

If the cancer has spread to other parts of the body (metastasised), you may still be offered surgery. 

The type of operation your surgeon recommends will depend on your individual situation. Read more about surgery for advanced bowel cancer.

Recovery time − This varies depending on the type of surgery. You will probably be in hospital for 5–7 days, but it can take 2–3 months to fully recover.

Drips and tubes − You will be given fluids through a drip (also called an intravenous or IV infusion) until you can start eating and drinking again. You may need a drip for a few days. You may also have other tubes – from your bladder to drain urine (catheter) or from your abdomen to drain fluid from around the surgical area.

Pain relief − At first, you will need some pain relief. You will have patient-controlled analgesia (PCA), which delivers a measured dose of pain relief medicine when you push a button. Pain relief may also be given by a slow injection into a vein (intravenous or IV infusion) or by an injection into your spinal column (epidural or spinal anaesthetic).

Breathing exercises − You may also be shown some deep-breathing exercises to do to prevent a chest infection.

Blood clots − To reduce the risk of developing blood clots in your legs, you may wear compression stockings during surgery to apply pressure to your calves. Some people also wear a special cuff that applies intermittent pressure.

Changes in bowel and sexual function – Many people find that their bowel and bladder functions change. These usually improve within a few months but, for some people, it can take longer. Erection problems are also an issue for some men.

Changes to your diet – Find out more about changes to your diet.

Fatigue – It is normal to feel tired after surgery. Try to rest and only do what is comfortable. You might have to remind your family and friends that it may take several months to recover from surgery.

Temporary or permanent stoma – Find out more about stomas.

Watch this short video to learn more about surgery.