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Surgery for rectal cancer

Find out about different types of surgery for cancer of the back passage (rectal cancer).

If you have cancer of the large bowel (colon cancer) the types of surgery are different. 

You may have radiotherapy, or chemotherapy and radiotherapy together (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 small early stage 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. This is called trans anal endoscopic microsurgery (TEM). 

Diagram of transanal resection for rectal cancer

Total mesorectal excision

This is the most common type of surgery for rectal cancer.

 The surgeon removes:

  • the cancer and a border (margin) of healthy tissue around it
  • fatty tissue and a sheet of tissue from around the bowel (the mesorectum.)

The mesorectum is a sheet of tissue surrounding the intestine, bowel, and rectum. It contains blood vessels and lymph nodes. It is possible that cancer cells might have spread to the mesorectum. 

A specialist doctor (pathologist) tests the cells in the surrounding tissue (margin) to check for cancer cells. If there are no cancer cells, this is called a clear margin.  

This operation lowers the risk of the cancer coming back. There are different types of total mesorectal excision depending on where the cancer is in your rectum, and how big it is. 

Cancer high in the back passage (rectum) 

Your surgeon will remove the cancer in the top part of the rectum. They attach the end of the colon to the remaining part of the rectum. The join is called an anastomosis.

 The surgeon removes the mesorectum to 5cm below the bottom edge of the tumour. Leaving some of the mesorectum in place, reduces the risk of a bowel join leaking after surgery. 

This operation is called an anterior resection. You might need to have a temporary stoma after this operation.

Cancer in the middle of your back passage (rectum)

Your surgeon will remove most of your rectum and attach the bowel (colon) to your anus.

Sometimes your surgeon will create a pouch by folding back a small section of colon or by enlarging a section of the bowel (colon). This small pouch works like the rectum did before surgery.  

This operation is called a colo anal anastomosis. You might need to have a temporary stoma after this operation.

Cancer low in the back passage (rectum) 

Your surgeon might not be able to leave enough of the rectum behind for it to work properly. Your surgeon removes the anus and rectum completely.

This operation is called an abdomino-perineal resection (AP resection). You will have a permanent colostomy after this operation. After this surgery you will have one wound on your tummy. And you will have another wound on your bottom where the surgeon has removed your anus and closed the skin. 

Diagram of TME for rectal cancer

How you have surgery

Open surgery 

This means your surgeon makes one long cut down your abdomen to remove the cancer. 

Keyhole (laparoscopic) surgery 

Your surgeon makes several small cuts in your abdomen. They pass a long tube with a light and camera through one of the holes. Surgical instruments are put into the other holes and are used to remove the cancer. 

Keyhole surgery can take longer than open surgery, but generally people recover quicker. 

Your surgeon might offer you keyhole surgery if they need to remove part of your bowel. But it depends on your situation, and some people aren’t able to have keyhole surgery. Sometimes the surgeon has to switch from keyhole to open surgery during the operation. Your surgeon will talk to you about this before your operation. 

Robotic surgery 

Some surgeons use a robotic system to help with keyhole surgery. The surgeon sits slightly away from you and can see the operation on a magnified screen. The robotic machine is next to you. 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 cancer.

Doctors hope that robotic surgery might lower the risk of:

  • your surgeon needing to switch to open surgery 
  • complications during and after surgery

Robotic surgery is still a new technique and not all hospitals in the UK have this. It also isn’t possible for all types of rectal cancer. You can talk about this with your surgeon.

Information and help

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