Types of surgery for rectal cancer

Surgery to remove the cancer is the most common treatment for rectal cancer. Surgery may also be done to treat a blocked bowel or cancer that has spread to other parts of the body.

The most common operation to remove cancer from the rectum is a total mesorectal excision (TME). The surgeon removes part or all of the rectum, depending on the size of the cancer and where it is. A TME may be done laparoscopically (keyhole surgery). The surgeon makes several small cuts in the tummy and uses special tools to see inside the rectum and remove the cancer.

After bowel surgery some people have an opening on the tummy wall to pass bowel motions through. This is called a stoma. A bag over the stoma collects bowel motions. A stoma may be temporary to let the bowel rest after surgery. But it can sometimes be permanent. Your surgeon will talk to you about your operation and if you need a stoma.

Surgery for rectal cancer

Surgery is the most common treatment for rectal cancer.

You may have radiotherapy or chemoradiation before surgery. This can make it easier to remove the cancer. It also lowers the risk of the cancer coming back in the rectum or in the tissues close to it.


Surgery to remove rectal cancer

There are different techniques and types of operation that can be used. The type your surgeon recommends will depend on the stage of the cancer, where it is in the rectum and your general health.

After the operation, all the tissue that the surgeon has removed will be sent to a pathologist. They will check the tissue carefully for any cancer cells close to the cut ends (the margins). If they find cancer cells in the margins, it is possible that not all of the cancer was removed during the operation. This is not common, but if it happens you may be offered a second operation or radiotherapy.

Local resection

Very small, stage 1 rectal cancers can sometimes be removed using a local resection. This is a small operation to remove the cancer and some healthy tissue surrounding it.

The surgeon inserts an endoscope up the rectum to remove the cancer. An endoscope is a long, flexible tube with a tiny camera at the end. This surgery is called transanal endoscopic micro surgery (TEMS).

If the cancer is very low in the rectum, close to the anus, the surgeon may not need an endoscope. They may be able to remove the cancer by passing surgical instruments up the anus. This is called a transanal rectal resection.

Total mesorectal excision (TME)

This is the most commonly used operation to remove rectal cancer. The surgeon removes the part of the rectum that contains cancer, as well as some healthy bowel on either side. They also remove the fatty tissue (mesorectum) around the rectum, which contains blood vessels and lymph nodes. Removing the mesorectum reduces the risk of any cancer being left behind. In the illustration below, the black dotted line shows an example of the tissue that may be removed during a TME operation.

Total mesorectal excision
Total mesorectal excision

Open or laparoscopic surgery

Your operation may be carried out as open surgery or as laparoscopic (keyhole) surgery.

Open surgery means the surgeon makes one large cut (incision). Afterwards, you have a wound that goes down in a line from just below your breastbone (sternum) to just below the level of your tummy button (navel). Some people have a wound that goes across their tummy instead.

In laparoscopic (keyhole) surgery, the surgeon makes four or five small cuts in the abdomen rather than one big cut. They pass a laparoscope into the abdomen through one of the cuts. A laparoscope is a thin tube containing a light and camera. Then they pass specially designed surgical tools through the other cuts to remove the cancer.

Recovery from laparoscopic surgery is usually quicker than recovery from open surgery. Your surgeon will talk to you about which type of surgery is appropriate.

Illustration showing laparoscopic surgery
Illustration showing laparoscopic surgery

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Types of TME operation

There are different types of TME operation. The type your surgeon recommends will depend on where the cancer is in your rectum, the size of the tumour and how far it is from the anus.

Anterior resection

An anterior resection is usually used for cancers in the upper and middle parts of the rectum (close to the colon).

After the piece of bowel that contains the cancer is removed, the surgeon rejoins the two open ends of bowel. The illustrations opposite show the part of the bowel that is removed, and how the two ends are joined together.

Some people may have a temporary stoma (usually an ileostomy) after this operation. A stoma reversal operation can usually be done a few months later.

Anterior resection - area to be removed
Anterior resection - area to be removed

 

Anterior resection - bowel has been rejoined
Anterior resection - bowel has been rejoined

Colo-anal and ‘J pouch’ surgery

This operation may be used for tumours low in the rectum. The surgeon removes all of the rectum and attaches the colon to the anus. Sometimes, the surgeon makes a pouch (called a J pouch) from part of the colon, before joining it to the anus. The pouch acts like a new rectum and stores bowel motions until it is convenient to pass them. The illustration below shows a J pouch.

You may have a temporary stoma (usually an ileostomy) after this operation. This allows the bowel to heal. A stoma reversal can usually be done a few months later.

J-pouch
J-pouch

Abdomino-perineal resection (APR)

This operation is usually used for cancers that are very low in the rectum, near to the anus. In order to remove all of the cancer, the surgeon needs to remove the rectum and anus. You will have a permanent stoma (usually a colostomy) after this operation.

As well as the wound(s) on your tummy, you will have a wound on your bottom, where the anus has been closed.

Abdomino-perineal resection
Abdomino-perineal resection

Permanent stoma
Permanent stoma

Colostomy bag
Colostomy bag


Stomas (colostomy/ileostomy)

After an operation to remove rectal cancer, some people will go to the toilet in a different way. They will have an opening on their tummy wall through which they pass bowel motions. This is called a stoma. A bag is worn over the stoma to collect bowel motions.

The stoma is made from an opening in part of the bowel. If the stoma is made from an opening in the colon, it is called a colostomy. If it’s made from an opening in the small bowel (ileum), it is called an ileostomy.

Stomas can be temporary or permanent. A surgeon may make a temporary stoma to allow the bowel to rest after rectal cancer surgery.

There are two kinds of stoma: a loop stoma and an end stoma. To make a loop stoma, the surgeon pulls a small loop of bowel out through a cut in the tummy (abdomen). They then make an opening in the loop of bowel and stitch the loop to the skin. This forms the stoma.

To make an end stoma, the surgeon cuts the bowel and brings the active end out onto the skin and stitches it into place. This forms a stoma.

If you have a temporary stoma, you will usually have a second smaller operation a few months later to close the stoma and rejoin the bowel. This operation is called a stoma reversal.

If the cancer is very low in your rectum, close to the anus, you are more likely to need a permanent stoma.

Your surgeon will tell you whether you are likely to have a stoma after your operation, and whether it will be temporary or permanent.

Living with a stoma

Nurse Gail Kerr talks about stomas and preparing stoma patients physically and psychologically for having a stoma.

About our cancer information videos

Living with a stoma

Nurse Gail Kerr talks about stomas and preparing stoma patients physically and psychologically for having a stoma.

About our cancer information videos


Surgery for advanced rectal cancer

Pelvic exenteration

If the cancer has grown into other organs nearby, some people need a bigger operation to try to remove it. This is called a pelvic exenteration. Your doctor will explain more about this operation if it is appropriate for you.

We have more information about pelvic exenteration for men and pelvic exenteration for women.

Lung resection

The main treatment for cancer that has spread to the lungs is chemotherapy. But occasionally, people may be offered surgery to remove the affected part of the lung. This is only if the cancer is in just one area of the lung and nowhere else in the body.

Liver resection

If rectal cancer has spread to the liver, the most common treatment is chemotherapy. The aim is to shrink the cancer and to control it for as long as possible.

Some people may be able to have surgery to remove the part of the liver affected by cancer. This operation is called a liver resection. It can sometimes lead to a cure.

Liver resection is a major operation that takes 3–7 hours. It is done by surgeons experienced in liver surgery (hepatobiliary surgeons) in specialist hospitals. This treatment is only suitable for a few people with secondary liver cancer.

An operation to remove the cancer in the rectum may be done at the same time or as a separate operation.

If you have secondary liver cancer, you can talk to your doctor about whether this surgery may be helpful for you. A course of chemotherapy is usually given before liver resection.

We have more information about other treatments for rectal cancer that has spread to the liver.


Treating a blocked bowel (bowel obstruction)

Sometimes, colon cancer can narrow the bowel, stopping bowel motions from passing through. This can cause symptoms such as tummy pain and vomiting. It usually needs to be treated urgently. It can be treated in one of two ways.

Stenting to relieve a blocked bowel

The surgeon uses a colonoscope to insert an expandable metal tube (stent) into the blockage. The tube then expands to hold the bowel open.

The cancer causing the blockage can usually be removed with an operation at a later date.

Cross-section of a part of the bowel, showing a stent inside
Cross-section of a part of the bowel, showing a stent inside

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Surgery to relieve a blocked bowel

Sometimes, a bowel obstruction is treated with an operation to remove the blocked section of bowel. Most people will have a temporary or permanent stoma after this operation. The surgeon may remove the cancer at the same time or do this later in another operation.

Back to Surgery explained

What happens after surgery?

Your specialist nurse will help you recover after surgery and you’ll probably be ready to go home after 3–7 days.

Bowel function after surgery

If you have problems with bowel function after surgery, talk to your surgeon or nurse. There are treatments that can help.

If you have a stoma

Adjusting to a stoma takes time but most people manage well with support from their stoma care nurse.