Surgical removal of the rectum

The day before surgery, the bowel will be emptied with a special preparatory procedure for the bowels (‘irrigation'). This reduces the risk of leakage after surgery.

Your attending physician will discuss with you which medications you use at home should be stopped in advance.

In consultation with the anaesthetist, you may choose to have an epidural catheter placed in your back just before the procedure. You can use those for pain relief after the procedure. Because you can operate the pain relief pump yourself, your level of comfort will be increased. If you or your anaesthetist do not opt for epidural pain relief for a specific reason, pain relief can be administered through the IV drip after the procedure.

Rectal surgery through a classic incision or through keyhole surgery?

• For keyhole surgery, or laparoscopy, a camera is introduced into the abdominal cavity through a small incision in the skin. The rest of procedure is performed with microsurgical instruments that are also introduced through small incisions in the skin. Large studies have demonstrated that a substantial number of malignant tumours in the large intestine and rectum can be removed equally well using this technique as with a large wound. In fact, by avoiding classic larger incisions in the abdominal wall, keyhole surgery has a number of advantages. Limiting the damage to the abdominal wall means that you will be mobile sooner, and the chance of wound infections and of developing incisional hernias later is smaller. There is also an aesthetic advantage of course, although that is not a decisive factor.

• However, not everyone is eligible for keyhole surgery. After extensive prior abdominal surgery, abdominal adhesion may be such that keyhole surgery is not smooth. Larger, more extensive cancers or metastatic tumours usually cannot be treated through keyhole surgery equally well. If, during keyhole surgery, the attending surgeon is uncertain as to whether the operation can be performed as well as in open surgery, the procedure will be continued with a classic abdominal incision.

Technical aspects

If the malignant tumour in the rectum is located far above the sphincter, the anus and sphincter can be spared during surgery. In this case, we can connect the upper colon to the remaining part of the rectum just above the anus.

To replace the reservoir function of the rectum, the surgeon may opt to construct a 'new rectum' during surgery. This can be done by connecting the colon to the anus in a J-configuration (as a 'J-pouch'). This construction can certainly have a positive effect on the frequency of bowel movements and therefore, post-operative comfort. However, connecting this new rectum to the sphincter is technically more complicated. The higher number of staple rows in the large intestine increases the risk of complications (especially in irradiated environments). To prevent the risk of leakage and resulting infections, our department almost always creates a protective stoma ('ileostoma’) on the small intestine. This ensures that the bowel content is collected temporarily in a bag on the abdominal wall, allowing the delicate junction near the anus to heal perfectly. After about two months, this temporary stoma can be removed in a minor procedure. Afterwards, the normal intestinal passage recovers.

For various reasons, it may become clear during the operation, that it is not possible to construct a new reservoir. In these cases, it often turns out to be possible to spare the anus and to reconnect the large intestine to the sphincter. After such a procedure, there is a slightly higher chance that the frequency of bowel movements remains slightly higher afterward.

If the malignant tumour in the rectum is located very close to or even against the sphincter, it is usually not possible to save the sphincter. To obtain a safe margin around the cancer, it is often necessary in this situation to remove the entire rectum as well as the anus and associated sphincter. This procedure is called ‘rectum amputation’ or abdomino-perineal resection (APR). Since this would mean that there is no longer any control of leakage of stools through the anus, a permanent stoma is created on the left side of the abdomen. If possible, the stoma nurse will determine the best location for the stoma on the abdomen before the procedure.

After the procedure, you will wake up on a ‘monitored ward’ (e.g. the intensive care department). Here, your breathing, blood pressure and heart rate will be carefully recorded during the first evening and night. We do this to detect any potential early post-operative problems, such as bleeding, at an earlier stage. Patients can usually move to the ward the following morning.

Because the bowels do not function well immediately after the surgery, it may be necessary to keep the stomach empty by means of a tube through the nose. Although we will try to remove this tube as soon as possible, it may be necessary to keep it in a bit longer. As soon as bowel function resumes, you can gradually start on fluids and light meals. If necessary, nutrients can be administered temporarily through an IV drip.

Because urinary function may be disrupted due to the pain relief pump and the procedure itself, a catheter will be inserted in the bladder. This usually only remains in place for a few days. If urinary problems persist afterward, it may be necessary to return the urinary catheter.

Wound infections occur slightly more frequently in relation to bowel surgery than other procedures. Sometimes, these infections can be treated with antibiotics. Occasionally, an infected wound is opened slightly to ensure good drainage of the infection. Afterward, the wound can continue to clear up and heal through daily care with ribbon gauze.

Any surgery of the large intestine or rectum carries a risk of leakage from the created bowel junction. Although rare, such leakage is a serious complication where bacteria spill into the abdominal cavity from the bowel and may cause peritonitis. Usually, this required repeat urgent surgery. Sometimes a stoma has to be created after all. Precisely to minimise the severity of these complications, a 'protective' stoma is almost always created during rectal surgery to be on the safe side.

Anatomically, the nerves that ensure normal sexual and urinary function are located behind the mesorectum, which must be removed in conjunction with the rectum. In the case of locally extensive cancers, these fibres may need to be sacrificed. As a result, sexual function and normal urinary function may be temporarily or even permanently impaired. This can result in erectile dysfunction, reduced sexual experience or difficulty in emptying the bladder properly.