Colorectal Cancer: Surgery

Surgery is often part of the treatment for colorectal cancer. Different kinds of surgery may be done. Which type you have depends on the type of cancer, where it is, how much it has spread, and other factors. 

When surgery may be an option

Colorectal polyps and early stage colorectal cancers are often first seen during a colonoscopy. If you have a colonoscopy, your doctor may see a polyp that might turn into cancer or might already have cancer. The doctor might be able to completely remove the polyp by passing small tools through the tube or colonoscope. No surgical cut or incision is needed.  

In other cases, surgery might be needed:

  • You've had a colonoscopy, but the doctor could not completely remove a polyp. Surgery is then needed to remove the rest of the polyp. That's because it might contain cancer cells that could spread to other areas. The only way to know if a polyp has cancer is to remove all of it and check it under a microscope.

  • You've had a polyp completely or partly removed, and that polyp has invasive cancer cells in it. Your doctor will be able to tell this by looking at the polyp under a microscope. Surgery may be needed because the cancer may have spread beyond the polyp. If your doctor thinks the cancer has not spread, you may not need surgery.

  • You have a stage I, II, or III colorectal cancer. These cancers have not spread to distant sites, so surgery may be able to remove all of the cancer. Other treatments such as chemotherapy or radiation therapy may be needed as well.

  • You have stage IV (advanced) colorectal cancer, but it has only spread to areas of the liver or lungs that can also be removed with surgery. Surgery on both the main tumor and the site where it has spread may be able to remove all of the cancer in certain cases. Other treatments such as chemotherapy or radiation therapy may be needed as well.

  • You have advanced cancer that threatens to block or obstruct the colon or cause other major problems. In these cases, surgery may be used, but not to try to cure the cancer. Instead it may be used to fix the problem and ease symptoms. For example, if the colon is blocked by a tumor, surgery may be done to create a colostomy. This connects the part of the colon before the blockage to an opening in the skin of the belly. This allows wastes to leave the body. 

Types of surgery

The type of surgery you have depends on the stage and location of the tumor, your health and preferences, and other factors. Surgery for colon and rectal cancers may include:

Polypectomy. This is the removal of a polyp, often done during a colonoscopy. It does not require an incision. 

Local excision. This is the removal of the cancer and a small area of the tissue around it. It is typically done during a colonoscopy to remove very shallow tumors. It may also be done in the operating room.

Surgical resection of the tumor. This is the removal of part of your colon or rectum and nearby lymph nodes. It is most often done through an incision in your belly. The type of surgery depends on whether the cancer is in your colon or rectum:

  • Colon cancer. The most common surgery for colon cancer is called a colectomy or hemicolectomy. The surgeon removes the part of the colon that has cancer, as well as a small amount of normal colon on either side. Nearby lymph nodes are removed as well and checked for cancer. This surgery can be done through 1 long incision in the belly, called an open colectomy. Or it can be done by using long, thin surgical tools passed through several smaller cuts in the belly. This is called a laparoscopic-assisted colectomy.

  • Rectal cancer. There are several different types of surgeries for rectal cancer. The type of surgery will depend on the stage of cancer and where it is in your rectum. Some early stage cancers can be treated with transanal resection and TEM or transanal endoscopic microsurgery. They use tools passed through the anus. There is no surgical cut in the skin.

Other more extensive rectal cancer surgery options include:

  • LAR or lower anterior resection .This surgery removes the part of the rectum that has cancer.

  • Proctectomy with colo-anal anastomosis. Removes the whole rectum. The colon is then joined to the anus.

  • APR or abdominoperineal resection. Removes the anus and the tissues surrounding it, including the sphincter muscle.

  • Pelvic exenteration. Removes the rectum as well as nearby organs if the cancer has spread there. These include the bladder, the prostate in men, or the uterus in women.

Risks and possible side effects

All surgery has risks. Some of the risks of any major surgery include:

  • Reactions to anesthesia

  • Excess bleeding

  • Blood clots in the legs or lungs

  • Damage to nearby organs

Risks from colorectal surgery

Along with the risks above, colorectal surgery can sometimes cause these problems:

  • Infection. Colorectal surgery increases your risk of infection because of the bacteria in your colon. Treatments before surgery can help reduce this risk. But a small portion of people who have colorectal surgery get an infection, either at the incision site on the skin or inside the abdomen. Doctors can treat some skin infections by letting them drain and by using clean dressings. More serious infections can occur inside the abdomen. These may require additional surgery. Antibiotics are very helpful to treat infections.

  • Anastomotic leak. After the surgeon removes a section of colon, he or she often links the two ends together. A leak can occur at this connection. Then what's in your intestine can leak into your abdomen. If the leak is small, the only treatment may be to watch the area and to be careful about your diet, letting the colon heal itself over time. If the leak is large, it can be life-threatening. You may need surgery to correct it. Leaks occur in a small number of people who have a colorectal resection.

  • Bowel blockage. Sometimes your colon develops scar tissue or adhesions while it heals. This can block your intestines and cause symptoms such as pain, bloating, nausea, and vomiting. If these adhesions block the intestines, you may need surgery to fix the problem.

  • Colostomy or ileostomy. Depending on the stage and location of the cancer, the surgeon might not always be able to reconnect the ends of the intestines after removing the tumor. In these cases, the piece of the colon (or the ileum, the last part of the small intestine) above the tumor is linked to a small hole or stoma made in the belly. This lets waste out of the body. A small bag is then placed over the stoma to collect the waste. For some people, an ostomy (colostomy or ileosotomy) might only be needed for a short time until the bowel can heal itself. Then the ostomy is reversed, and the ends of the intestines are reconnected in another surgery at a later time. Other people may need a permanent ostomy. 

  • Changes in bowel function or what you can eat. Some people might need to change their diets and might have different bowel patterns after surgery (see below). 

There are also some specific risks that can come from surgery to remove a tumor from your rectum:

  • Ureteral injury. The tubes that carry urine from your kidney to your bladder are called ureters. Sometimes they can be damaged during surgery. If they are, the doctor can usually fix them during the procedure. If the damage isn't noticed, sometimes there can be long-term problems.

  • Erectile dysfunction. In men, the rectum is close to the prostate. The nerves that are involved in sexual function wrap around the prostate. Sometimes these nerves are damaged. This can cause problems with getting an erection, or erectile dysfunction.

Even with these possible problems, the benefits of removing a tumor usually outweigh the risks.

Getting ready for your surgery

A few days before your surgery, your doctor will prescribe laxatives and enemas to help clean out your colon. Your doctor will tell you when and how to use these. You may also be told to follow a special diet.

Before you have surgery, you will meet with your surgeon to talk about the procedure. After you have discussed all the details of the surgery, you will sign a consent form. This gives the doctor permission to perform the surgery.

You will also meet with the anesthesiologist. This is the provider who will give you general anesthesia, the medicine that puts you to sleep so that you won't feel any pain during surgery. He or she also monitors you during surgery to keep you safe. He or she will ask about your medical history and your medicines.

What to expect during surgery

When it is time for your surgery, you will be taken into the operating room. Your healthcare team will include the anesthesiologist, the surgeon, and nurses.

During a typical surgery:

  • You will be moved onto the operating table.

  • Someone will place special stockings on your legs. These are to help prevent blood clots.

  • You will have electrocardiogram (EKG) electrodes put on your chest. These are to keep track of your heart rate. You will also have a blood pressure cuff on your arm.

  • You will be given anesthesia through an IV or intravenous line into your arm or hand.

  • When you are asleep, the surgeon will do the surgery.

  • A urinary catheter will be put into the bladder during surgery.

What is removed during surgery and where your incisions are will depend on the type of surgery you have. This is based on where the tumor is.

What to expect after surgery

You will wake up in a recovery room. You will be watched closely by healthcare providers. You will be given medicine to treat pain.

You may have to stay in the hospital for up to 7 days, depending on the type of surgery you have. People who have a laparoscopic-assisted colectomy can often go home sooner. That’s because they have smaller incisions that can usually heal faster.

You can slowly return to most normal activities once you leave the hospital. But you should not lift heavy things for several weeks. Always follow the instructions you get from your doctor or nurse.

It will take time to get back to eating normally and having regular bowel movements. If you have an ostomy, you'll also learn how to take care of your hole or stoma. You will still have the urinary catheter in your bladder to drain urine. It is usually removed before you go home.

After surgery, you may feel weak or tired for a while. The amount of time it takes to recover after surgery will vary for each person. But you will probably not feel like yourself for a few months. You will be able to get your incision wet. But to reduce your risk of infection, don’t take baths or go swimming. You likely won't be able to drive for a while, as directed by your healthcare providers.

If you had an open surgery, you may have a 5-to-7-inch scar running up and down through your belly button. This will likely heal into a thin scar.

After surgery, you may have either chemotherapy or radiation to reduce the chance that any remaining cancer cells will spread. Treatment after surgery is called adjuvant therapy.

Eating after surgery 

You may not be able to eat for the first few days after surgery. You may get some nutrients through an IV line that’s put into one of your veins. At first, you will be on a clear liquid diet until there are signs that your bowels are moving again. Then you may be able to add some soft foods and then normal foods. It may take your colon several months to heal after surgery. To rest your bowels, your healthcare provider may advise that you eat a low-fiber diet. Be sure you talk about your diet with your provider. Your provider may refer you to a nutritionist or dietitian to help you plan your meals.

Bowel function after surgery

After having a section of your colon removed, you may have more bowel movements than normal. Some people have 7 or 8 a day in the first months after surgery. You may also have a more urgent need to have a bowel movement. This means that once you feel the urge, you may have to get to the bathroom quickly to avoid leaking. These side effects usually get better over time. It may take as long as 2 years to fully adjust. Even then, you’re likely to have bowel movements several times a day. And you may still have bowel urgency.

If your tumor was in the rectum, your surgeon may have made a special pouch called a J-pouch, to holds stool as your rectum did before surgery. Your surgeon forms the J-pouch during the same surgery to remove your rectum. The surgeon loops the colon back on itself and staples it together. This creates a pouch that looks like the letter J. Stool collects there until you can get to a bathroom. This helps you to get back to a stable bowel pattern more quickly after surgery. You may be able to have stable bowel function after a few months.

Depending on the type of surgery you had, your doctor may have created an ostomy in your belly. This allows waste to leave your body. This may be short-term or permanent. If you have an ostomy, a specially trained therapist can help you learn how to care for it and adjust to having one.