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 using laparoscopic surgery (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 poo (stools) through. This is called a stoma. A bag over the stoma collects poo. 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 into 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 and 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 diagram below, the black dotted line shows an example of the tissue that may be removed during a TME operation. There are different types of TME operation.

The large bowel and mesorectum
The large bowel and mesorectum

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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 (abdomen) instead.

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

A surgeon performing laparoscopic surgery
A surgeon performing laparoscopic surgery

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Laparoscopic surgery is sometimes used when the cancer is small. It uses a specialised technique and is not available in all hospitals. If this surgery is the best type for you to have, you may be referred to another hospital to have it done. Recovery from laparoscopic surgery is usually quicker than recovery from open surgery. Your surgeon will talk to you about which type of surgery is likely to be best in your situation.

Stomas (colostomy or ileostomy)

During the operation to remove the cancer, an opening is sometimes made through the tummy (abdominal) wall. This lets the bowel connect to the surface of the tummy. It is called a stoma. It is round or oval, and it looks pink and moist. The stoma has no nerve supply, so it doesn’t hurt.

Poo (stools) will no longer pass out of the rectum and anus in the usual way. Instead it will pass out of the stoma, into a disposable bag that is worn over the stoma.

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 is 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 heal after surgery.

There are two kinds of stoma:

  • a loop stoma
  • an end stoma.

To make a loop stoma, the surgeon pulls a small loop of bowel out through a cut in the tummy. 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 removes the section of bowel that contains cancer. This leaves two open ends of bowel. The surgeon brings the active end out to the surface of the tummy and stitches it into place. This forms a stoma. The inactive end of bowel, which leads to the rectum (back passage), is stitched closed and left inside the tummy.

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 and 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.

If you need to have a stoma, you will be referred to a stoma nurse who specialises in stoma care.


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 diagrams 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 can usually be done a few months later.

Anterior resection – area to be removed
Anterior resection – area to be removed

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

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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 poo (stools) until it is convenient to pass them. The diagram 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 surgery
J pouch surgery

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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 on your tummy, you will have a wound on your bottom where the anus has been closed.

Abdomino-perineal resection - area to be removed
Abdomino-perineal resection - area to be removed

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Permanent stoma formed after abdomino-perineal resection
Permanent stoma formed after abdomino-perineal resection

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Colostomy bag outside the body
Colostomy bag outside the body

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I’ve had so much help from doctors, nurses, social workers, the surgeon, everybody. And the surgeon went into every detail with me, which I think helped.

Meera


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 in men and women.

Liver resection

If rectal cancer has spread to the liver, the most common treatment is chemotherapy. The aim is to shrink the cancer and 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 three to seven 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.

Sometimes the liver resection is done at the same time as an operation to remove the cancer in the rectum. But it is usually done 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 information about other treatments for secondary cancer in the liver.

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 usually only possible if the cancer is in just one lung, although some surgeons will operate on both lungs in certain circumstances. Radiofrequency ablation may sometimes be used.


Treating a blocked bowel (bowel obstruction)

Sometimes, rectal 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.

A part of the bowel with a stent inside
A part of the bowel with 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.

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If you have a stoma

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