What is it?

The purpose of this operation is to remove the malignant tumour with a safe margin. The surrounding fatty tissue containing the lymph nodes (the so-called mesorectum) is also removed at the same time. Thanks to this principle of ‘Total Mesorectal Excision (TME)’, the chance of the cancer ever recurring in the area of the operation is very small.

Preparation

The day before surgery, the bowels will be cleared by means of a special preparatory procedure (‘irrigation’) to minimise the risk of leaks after the procedure.

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 opt to have an epidural catheter placed in the back just before the procedure; this can be used 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.

Process

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 subsequent procedure is then performed using 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 through a large incision (equal margin around the tumour, equal number of lymph nodes, etcetera)

By avoiding the classic larger incision in the abdominal wall, keyhole surgery even offers several advantages. Limiting the damage to the abdominal wall means that you will be mobile sooner, the chance of wound infections is smaller and incisional hernias develop later. There is an aesthetic advantage too of course, but in the case of cancer treatment, that is naturally not a deciding factor.

However, not everybody is a good candidate for keyhole surgery: after previous extensive abdominal surgery, the degree of adhesion in the abdominal cavity is often such that it makes keyhole surgery difficult. Larger, more extensive cancers or metastatic tumours usually cannot be treated through keyhole surgery equally well. If, during the keyhole surgery, the surgeon is uncertain whether the procedure can be performed equally well as open surgery, the procedure will be continued through 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, the large intestine higher up can be connected 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 achieved by, among others, connecting the large intestine to the anus in the form of a J-shaped configuration (a ‘J-pouch’). This construction can certainly have a positive effect on the frequency of bowel movements and therefore, post-operative comfort. However, connecting the newly constructed rectum to the sphincter is more complicated in technical terms: the higher number of staple rows in the large intestine increases the chance of complications (and certainly so after the area has been subject to radiation therapy). To avoid the risk of leaks and resulting infections, our department almost always creates a protective stoma on the small intestine (ileostomy). This ileostomy 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 two months, this temporary ileostomy can be removed in a small procedure, after which normal passage through the bowels resumes.

For various reasons, it may not be possible to construct a new rectum during the procedure. 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 near or up against the sphincter, it is usually not possible to spare the sphincter. To obtain a safe margin around the cancer, it is often necessary in this case to not only remove the entire rectum but also 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

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 if bowel function is slow to resume. 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 placed 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.

Possible complications

No operation is risk free. Surgery of the rectum also carries a certain risk of classic complications such as pneumonia, bleeding or deep vein thrombosis. To avoid such classic post-operative complications, it is useful to stop smoking a few weeks before surgery. After the procedure, the physical therapists will start mobilisation as soon as possible.

Wound infections

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.

Anastomotic leak

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 requires urgent repeat surgery and sometimes a stoma has to be created after all. It is to limit the severity of precisely this complication to a minimum that a ‘protective’ stoma is almost always created during rectum surgery, for reasons of safety.

Disrupted sexual and urinary function

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, it may be necessary to sacrifice these nerve fibres. This may disrupt sexual function and normal urinary function temporarily or even permanently. This may result in erectile dysfunction, reduced sexual pleasure or inability to fully empty the bladder.

Results

The removed bowel segment including the tumour will be extensively, microscopically examined in the days following the procedure. Based on this information, we can learn more about the level of aggression and extent of the tumour. This gives us an idea about your prognosis and about the chance that the cancer will ever recur. Based on this information, the oncologist can discuss with you if you will benefit from additional chemotherapy or radiation therapy.

Advice about potential additional treatment will only be given after a MOC meeting (Multidisciplinary Oncology Consultation). This is a weekly meeting where all specialists who are involved in the treatment of cancer jointly discuss their patients. Your GP will also be invited to this meeting. However, the decision reached in this meeting is only advisory and will then be discussed with yourself to arrive at a treatment plan that meets your personal wishes.

Centres and specialist areas

General Surgery

Latest publication date: 05/02/2021
Supervising author: Dr Pletinckx Pieter