Types of surgery for rectal cancer

Most people with rectal cancer have surgery. There are different types of surgery for rectal cancer.

The operation that is most suitable for you depends on:

• whether your cancer is in the low, middle or high part of the rectum
• how far it has grown or spread (the stage) - for rectal cancers, doctors use the TNM staging system

Total mesorectal excision (TME) is the most common type of rectal cancer surgery.

Other types of surgery for rectal cancer include:

• endoscopic mucosal resection (EMR)

• endoscopic submucosal dissection (ESD)

• trans anal minimally invasive surgery (TAMIS)

• trans anal endoscopic operation (TEO)

• trans anal endoscopic microsurgery (TEMS)

Surgery to the large bowel (colon) is different to rectal cancer surgery.

Treatment decisions

Your healthcare team uses your MRI scan results to help plan treatment. The aim is to completely remove your cancer with a clear border, or margin, of tissue. A specialist doctor (pathologist ) tests the cells in the surrounding tissue to check for cancer cells. If there are no cancer cells, this is called a clear margin.

Your team consider how likely it is that your cancer will come back after surgery and decide if you need:

• surgery on its own

• surgery after radiotherapy with or without chemoradiotherapy

• total neoadjuvant treatment (TNT) - this is radiotherapy and surgery together with an extra course of chemotherapy, all before surgery

After your operation, the pathologist looks closely at your cancer. A very small number of people might need further treatment. This is usually if the pathologist’s report shows your risk of cancer coming back is higher than the surgeon previously thought.

Types of surgery

The two main types of surgery are:

• local excision (including trans anal endoscopic microsurgery)
• total mesorectal excision (TME)

Local excision

You might have a local excision if you have a small early stage cancer with a low risk of it coming back.

Your surgeon removes the cancer through the back passage opening (anus). Your surgeon uses special equipment to do this.

Your surgeon might use a colonoscope to remove your cancer during a:

• endoscopic mucosal resection (EMR)
• endoscopic submucosal dissection (ESD)

Other options for removing the rectal cancer through the anus are:

• trans anal endoscopic microsurgery (TEMS)

• trans anal minimally invasive surgery (TAMIS)

• trans anal endoscopic operation (TEO)

Your bowel cancer MDT works together to decide the best operation for you. And your surgeon will let you know which type of local excision you are likely to have.

Having a local excision means you won’t have any wounds on your tummy (abdomen). This means you might recover more quickly than if you had an open operation. Many people have a local excision as day surgery. This means you don’t have to stay overnight in hospital.

Total mesorectal excision (TME)

This is the most common type of surgery for rectal cancer. The surgeon removes the part of the rectum that contains cancer, as well as a border (margin) of healthy tissue around it. They also remove the fatty tissue (mesorectum) around the rectum. 

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. 

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. This operation is called an anterior resection. The surgeon attaches the end of the colon to the remaining part of the rectum. The join is called an anastomosis.

The surgeon removes the mesorectum to a few cms below the bottom edge of the cancer. Leaving some of the mesorectum in place reduces the risk of a bowel join leaking after surgery. This is called a partial TME.

You may 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 or lower rectum.

This operation is called a colorectal or coloanal anastomosis. You might need to have a temporary stoma after this operation.

Cancer low in the back passage (rectum) 

Your surgeon removes the rectum. In some situations the 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.

If there is enough room left to join the bowel together you will have a TME and a temporary ileostomy . If there is not enough room then you will have an operation called an abdominoperineal resection (AP resection). You will have a permanent colostomy  after this operation.

After this surgery you will have one wound on your tummy (abdomen). Or you might have several small wounds if you had surgery robotically or laparoscopically (keyhole surgery). You will have another wound on your bottom where the surgeon has removed your anus and closed the skin.

A plastic surgeon  might use tissue from another part of the body to help the area heal. This is called a flap perineal reconstruction Or your surgical team might use a mesh to support the area.

An AP resection is a big operation. Your surgical team will give you lots of information beforehand and you have time to ask questions.

Stomas

Sometimes the surgeon brings the end of the bowel out as an opening on your abdomen called a stoma. There are two different types of stomas:

• ileostomy – part of the small bowel is brought to the surface of the tummy (abdomen)
• colostomy – part of the large bowel is brought to the surface of the tummy (abdomen)

Stomas can be temporary or permanent. There are different types of stomas:

• A loop stoma – your surgeon brings a loop of bowel to the surface of the abdomen. They then make a split in the loop to allow poo to come out. This is common in rectal cancer surgery.
• An end stoma – your surgeon closes one end of the bowel and brings the other end to the surface of the abdomen.

You might have a temporary stoma to allow your bowel to heal after surgery. Your surgeon joins the ends of the bowel back together in another operation. This is usually after a few months. This operation is called a stoma reversal. In the meantime, you wear a colostomy or ileostomy bag over the opening of the bowel to collect your poo.

You are more likely to need a permanent colostomy if the cancer is very low in your rectum. Occasionally there may be other reasons where a stoma might be needed instead of a join in the bowel. Your surgeon will talk to you about whether you are likely to need a stoma, and whether the stoma will be temporary or permanent. They will refer you to a specialist stoma nurse who will provide you with information and support before and after surgery.

Surgery if cancer blocks the bowel

Sometimes bowel cancer can cause a blockage. This is called bowel obstruction.

If this happens you will need an emergency procedure straight away. Your surgeon may put a tube called a stent into the bowel. Your surgeon passes the stent through a colonoscope which they gently insert into the lower bowel. The surgeon positions the stent to open up the blocked area. The stent holds the bowel open, allowing it to work properly again. Or you might have surgery to relieve the blockage.

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.

Generally, with keyhole surgery, 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 several 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.

Robotic surgery is still quite a new technique and not all hospitals in the UK have this option. 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 isn’t possible for all types of rectal cancer.

After rectal cancer surgery

Most people have problems with their bowel function for several weeks after rectal cancer surgery. For some people these problems can continue for around a year.

The problems should improve with time but it’s unlikely your bowel function will return to how it was before surgery. Let your specialist nurse or doctor know if you’re having problems after surgery. They can tell you about what you and your team can do to manage these changes.