Types of surgery for bowel cancer
This page tells you about the types of surgery used for bowel cancer (colorectal cancer). You can find the following information
Which surgery for bowel cancer?
There are different types of surgery for bowel cancer. The operation you have depends on where the cancer is in your bowel, its type and size, and whether it has spread.
If you have a very small, early stage cancer, the surgeon may just remove the cancer from the bowel lining, along with a border of healthy tissue. This operation 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 nearby lymph nodes in the abdomen, in case the cancer has spread there. With cancer of the back passage (rectal cancer), the surgeon usually also removes the sheet of body tissue that covers the bowel (the mesorectum).
To give the bowel time to heal, the surgeon may want to make a temporary colostomy or ileostomy. This is an opening from the bowel that leads to the surface of the abdomen and is called a stoma. Waste matter from the bowel collects into a special bag over the opening. You have another operation to repair the stoma after a few months. If you have a lot of your bowel removed, the surgeon may have to make a permanent stoma. But most people don't need this. The surgeon will discuss this with you before the operation.
Open or keyhole surgery
You may have your operation as open surgery or keyhole (laparoscopic) surgery. Open surgery means the surgeon makes one large cut down your abdomen to remove the tumour. With keyhole surgery, the surgeon makes several small cuts in your abdomen. Through these, the surgeon passes a long tube with a light and camera attached (laparoscope) and surgical instruments to remove the tumour. Keyhole surgery can take longer than open surgery, but people generally recover quicker. Your surgeon will talk to you about the risks and benefits of both types of surgery.
You can view and print the quick guides for all the pages in the treating bowel cancer section.
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 that a surgeon will not carry out any 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 bowel cancer are outlined below.
If you have a very small, early stage cancer of the large bowel or back passage, your surgeon may just remove the cancer from the bowel lining. This operation is called a local resection. The surgeon will also remove a border of healthy tissue from around the cancer. This is to try and make sure no cancer cells are left behind.
Your surgeon sends the tissue they've removed to the laboratory. A pathologist looks at the cells under a microscope to see how abnormal they 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. The second operation is to remove more tissue that could contain cancer cells and lower the chance of the cancer coming back.
The type of operation you have depends on where the tumour is in your large bowel (colon). The surgeon removes the part of the colon containing the tumour. This is called a colectomy. How much your surgeon takes away depends on the exact position and size of the cancer. Your surgeon will also remove the lymph nodes closest to the bowel, in case any cancer cells have spread there.
If the left side of the colon is removed, the operation 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 part of the bowel with the tumour, they join the ends of the colon back together. The join is called an anastomosis. Sometimes, to give the area time to heal, the surgeon brings the end of the bowel out as an opening on your abdomen called a stoma. If the small bowel is brought out onto the abdominal wall it is called an ileostomy. If the large bowel is brought out it is called a colostomy.
The stoma is usually temporary and the ends of the bowel are joined back together in another operation a few months later. This is called a stoma reversal. In the meantime, you wear a colostomy or ileostomy bag over the opening of the bowel, to collect your bowel motions. We have detailed information about stomas on our pages about having a colostomy and having an ileostomy.
If you have a large amount of colon removed or you are not in very good health, you may need to have a permanent colostomy or ileostomy. Your surgeon will avoid this if at all possible. You will be able to ask questions about why you need a stoma before you sign the consent form. Sometimes surgeons can't tell whether you will need a permanent stoma until during the operation. They may not know 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 the 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.
You may have radiotherapy, or chemotherapy and radiotherapy (chemoradiation) to shrink the cancer before surgery and make it easier to remove. This also lowers the chance of the cancer coming back in the back passage (rectum) after surgery.
If you have a very small, early stage rectal cancer, your surgeon may be able to remove it in an operation called a local resection (trans anal resection). The surgeon puts an endoscope (a flexible tube with a light) in through your back passage and removes the cancer from the wall of the rectum. Surgeons call this operation trans anal endoscopic microsurgery (TEM).
During most operations for rectal cancer, the surgeon removes the cancer with a border of rectal tissue around it that is free of cancer cells. They call this border of tissue a clear margin. They also remove fatty tissue from around the bowel and a sheet of body tissue called the mesorectum. This sheet of tissue 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 it. So any lymph nodes that contain cancer cells are likely to be in the mesorectum. Small groups of cancer cells may also spread into the mesorectum.
Taking the mesorectum away completely, along with a border of tissue immediately around the cancer, lowers the risk of the cancer coming back. This type of operation is known as total mesorectal excision or TME. There are different types of TME operation depending on where the cancer is in the rectum, and its size.
For cancers higher up in the back passage, your surgeon will remove the part of the rectum containing the tumour. This is called an anterior resection. The surgeon removes the cancer with a border of normal tissue on either side of it. The surgeon attaches the end of the colon to the remaining part of the rectum. They also remove the mesorectum down to 5 cm below the bottom edge of the tumour. They do not remove the whole mesorectum because then there is a greater risk of having a leaking bowel after surgery.
If your tumour is in the middle part of your back passage, your surgeon may remove most of the rectum and attach the colon to the anus (the opening of the bowel to the outside of the body). 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 stoma made, usually an ileostomy. You have this for about 8 weeks while the bowel heals. You then have a second operation to close the ileostomy opening. This is called a stoma reversal. Sometimes with a colo-anal anastomosis you may need to have a permanent stoma.
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 the surgeon removes your anus and rectum completely. This is called an abdomino-perineal resection (AP resection or APR for short). Then the surgeon makes a permanent colostomy opening on your abdomen. After this type of surgery, you have a wound or wounds on your abdomen and another wound where your anus has been closed.
You may have your operation as open surgery or keyhole (laparoscopic) surgery. With open surgery, the surgeon makes one large cut in your abdomen to remove the tumour. The cut may be from the bottom of your breastbone (sternum) down to the level of your hip bones.
With keyhole surgery, the surgeon makes several small cuts in your abdomen. They pass a long narrow tube called a laparoscope through one of the cuts. The tube has a light and camera attached so that the surgeon can see the inside of your abdomen. Through the other cuts, the surgeon passes surgical instruments to remove the tumour. Keyhole surgery can take longer than open surgery, but people generally recover quicker. Sometimes during keyhole surgery, the surgeon has to switch to open surgery instead. Your surgeon will talk to you beforehand about the risks and benefits of both types of surgery.
A few centres in the UK are using a robotic system to help with keyhole surgery. This is called robotic assisted laparoscopic surgery. With this type of surgery, the surgeon sits a few feet away from the patient and can see a magnified image of the operation on a TV screen. The robotic machine is next to the patient. The machine has 4 arms. One arm holds the camera, and the others hold the surgical instruments. The surgeon controls the arms of the machine to remove the tumour. Robotic assisted laparoscopic surgery may help to reduce the
- Number of times surgeons need to switch to an open operation
- Risk of complications during and after surgery
- Length of time people stay in hospital
Doctors are waiting for the results of trials to find out what difference robotic surgery makes compared to standard laparoscopic surgery.
Usually surgery for bowel cancer is planned in advance, after tests have found the cancer. But sometimes the cancer completely blocks the bowel at the time it is found. This is called bowel obstruction. In this situation you need an operation straight away. The surgeon may put a tube called a stent into the bowel during a colonoscopy. 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 information about this type of operation in the surgery for bowel obstruction section.
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