Which surgery for bowel cancer
This page tells you about the types of surgery used for bowel cancer (colorectal cancer). You can find information on
Which surgery for bowel cancer?
There are different types of surgery for bowel cancer. Which one you have depends on where the cancer is in the bowel, its type and size, and whether it has spread.
If you have a very small, early stage cancer, the surgeon might just remove the cancer from the bowel lining. They will also remove a border of healthy tissue. This is called a local resection.
If your cancer is larger, the surgeon will remove the part of the bowel where the cancer is and join the two ends back together again. They will also remove the lymph nodes in the abdomen in case the cancer has spread there. With rectal cancer, the surgeon usually also removes the mesentery – the sheet of body tissue that covers the bowel.
To give the area time to heal, the surgeon may want to make a temporary colostomy or ileostomy. This is an opening from the bowel on to the surface of the abdomen called a stoma. Waste matter is collected into a special bag over the opening. You have another operation to repair the stoma after a few months. If you have a large amount of bowel or rectum removed, the surgeon may have to make a permanent stoma. He or she will discuss this with you before the operation. Most people don’t need a permanent colostomy or ileostomy.
In the past few years surgeons have been developing keyhole surgery to remove early stage bowel tumours. This type of operation is called a laparoscopic resection.
The type of operation you have will depend on
- Where the cancer is in the bowel
- The type and size of the cancer
- Whether the cancer has spread
Before your operation your doctor will talk to you about the best type of surgery for you.
Remember - a surgeon will not carry out an operation without your consent. Your surgeon will answer your questions about the choice of operation before you sign the consent form.
The main types of operation for colorectal cancer are outlined below.
If you have a very small, early stage, cancer of the colon or rectum, your surgeon may just remove the cancer from the bowel lining. They will also remove a border of healthy tissue. This is called a local resection.
Your surgeon sends the removed cancer to the lab. In the lab, a pathologist looks at the cells under a microscope to see how abnormal the cells are. This tells your doctor the grade of the cancer. If the cells look very abnormal (high grade) your surgeon may decide you need a second, larger operation. This is to remove any cells that may have been left behind. And to make sure that the cancer is unlikely to come back.
The type of operation will depend on exactly where the tumour is in your colon. The surgeon makes a cut in your abdomen to remove the part of the colon containing the tumour. This is called a colectomy. How much your surgeon takes away depends on the position and size of the cancer. Your surgeon will remove the lymph glands close to the colon in case any cancer cells have spread into them.
If the left side of the colon is removed, it is called a left hemi colectomy.
If the middle part of the bowel is removed (the transverse colon) it is called a transverse colectomy.
If the right side of the colon is removed, it is called a right hemi colectomy.
If the sigmoid colon is removed it is called a sigmoid colectomy.
After your surgeon removes the part of the bowel containing the tumour, they join the ends of the colon back together. The place where they join is called an 'anastomosis'. Sometimes, to give the area time to heal, the surgeon makes a temporary colostomy or ileostomy higher up the bowel. You have the temporary stoma repaired in another operation a few months later. This is called a stoma reversal. In the meantime, you have a colostomy bag over the opening of the bowel. There is more information about having a colostomy and having an ileostomy in this section of CancerHelp UK.
If you have a large amount of colon removed, your surgeon may not be able to join together the ends of bowel that are left. You may need to have a permanent colostomy. Your surgeon will avoid this if at all possible. You will be able to ask questions about why you need a colostomy before you sign the consent form. Sometimes surgeons can't tell whether you will need a permanent colostomy until during the operation. This may be because it's not clear how big the tumour is, or how much of the bowel it affects. Your surgeon will explain this to you before the operation.
Surgery to remove whole colon is called a total colectomy. The surgeon makes a cut in the abdomen to remove the colon. They bring the upper end of the bowel out onto the surface of the abdomen to make a colostomy or ileostomy.
After these types of surgery you usually have a wound from the bottom of your breast bone (sternum) to just above your pelvis. Some people may have keyhole surgery for colon cancer instead of the open surgery described here.
You may have radiotherapy or chemoradiotherapy to shrink a tumour before surgery and make it easier to remove. It also reduces the chance of the cancer coming back in the rectum after surgery.
If you have a very small, early stage, rectal cancer, your surgeon may be able to remove just the tumour in an operation called local resection or 'transanal resection'. The surgeon puts an endoscope (a flexible tube with a light) in through your back passage to remove the cancer from the wall of the rectum. This operation is also called transanal endoscopic microsurgery (TEM).
During most operations for rectal cancer, the surgeon removes the tumour and some surrounding rectal tissue. They also remove the fatty tissue around the bowel and a sheet of body tissue called the mesentery. The mesentery surrounds the intestine, bowel and rectum. It contains all the blood vessels that supply the rectum and the lymph nodes that carry tissue fluid away from the rectum. So any lymph nodes that contain cancer cells are likely to be in the mesentery. Small groups of cancer cells may also spread into the mesentery. So, it is now standard procedure to remove the mesentery during rectal cancer surgery. This lowers the risk of the cancer coming back. As with all cancer surgery, the most important thing is ‘clear margins’. That means, your surgeon should remove a border of tissue around the tumour that is free of cancer cells. With TME surgery, it is possible to get clear margins in 9 out of 10 operations for rectal cancer.
For cancers in the upper part of the rectum, your surgeon will remove the part of the rectum containing the tumour. This is called a low anterior resection. The surgeon makes a cut in the abdomen and removes the cancer and a border of normal tissue on either side of the cancer. They will also remove the mesentery as far as 5 cm below the bottom edge of the tumour. They do not remove the whole mesentary because then there is a greater risk of bowel leaks after surgery to this part of the rectum. The surgeon then attaches the end of the colon to the remaining part of the rectum.
If your tumour is in the middle part of the rectum your surgeon may remove most of the rectum and attach the colon to the anus. This is called a 'colo anal anastomosis'. Sometimes the surgeon can make a small pouch by folding back a short section of colon or by enlarging a section of colon. This small pouch then works like the rectum did before surgery. During this operation you may have a temporary colostomy made. You have the temporary colostomy for about 8 weeks while the bowel heals. You then have a second operation to close the colostomy opening. Closing the colostomy is also called stoma reversal. Sometimes, with a colo anal anastomosis you may need to have a permanent colostomy instead of a temporary one.
If the cancer is in the lower part of your rectum, your surgeon will not be able to leave enough of the rectum behind for it to work properly. So, they remove your anus and rectum completely. This is called an abdominoperineal resection (AP resection for short). Then the surgeon will make a permanent colostomy opening on your abdomen. After this type of surgery you have 2 wounds - a wound on your abdomen and a second wound around the anus, where it has been closed.
In the past few years surgeons have been developing keyhole surgery to remove early stage bowel tumours. This type of operation is called a laparoscopic resection. The surgeon makes several small cuts in your abdomen instead of making one large cut (an open laparotomy). The surgeon passes a long tube called a laparoscope, and other instruments, through these cuts. They look through the laparoscope to do the operation. The surgeon then removes the tumour through as small a cut as possible in your abdomen. This type of surgery takes on average 40 minutes longer than a traditional open operation.
Keyhole surgery seems to be as good as the traditional open operation at getting rid of the cancer. Studies have also shown that people who have this type of surgery may have less pain afterwards. You can get back to normal more quickly too. You may also leave hospital sooner. In August 2006, the National Institute for Health and Clinical Excellence (NICE) issued guidance approving laparoscopic bowel surgery as a possible alternative to traditional open surgery for people with bowel cancer. But your doctor should talk to you beforehand about the risks and benefits of both procedures. And only surgeons with specialist training and regular experience in carrying out this technique should offer it. The NHS aims to offer this procedure in all hospitals by 2012.
Usually your surgery for colorectal cancer would be planned in advance, after your tests have found the cancer. But sometimes the cancer completely blocks the bowel and this is called a bowel obstruction. In this situation you need an operation straight away. The surgeon may put a tube called a stent into the bowel during an endoscopy. The stent holds the bowel open so that it can work normally again. Or you may have immediate surgery to remove the tumour from the bowel. There is more about surgery for bowel obstruction in this section of CancerHelp UK.
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