Colorectal Surgery

Right Hemicolectomy

This is an operation to remove the right side of the colon or part of it and usually part of the end of the small bowel. It is commonly performed for bowel cancer, other tumours, large polyps that cannot be removed at colonoscopy, and inflammatory conditions of the bowel, especially Crohn’s disease. Occasionally, appendicitis can be sufficiently damaging that it needs a right hemicolectomy to be performed.

 It can be performed “open” with an incision in the abdominal wall or laparoscopically, commonly called “key hole surgery”.

 After the end of the small bowel and the resected part of the right colon are removed, along with their blood supply, the two ends of bowel are joined together (anastomosed) with stitches or stapling devices.

 It is uncommon to require a bag or stoma in association with a right hemicolectomy.

You will require some time in hospital following the surgery – 2-5 days after laparoscopic procedure and up to 7 days after an open procedure, depending on how soon after the surgery you are able to tolerate a diet and comfortable enough to move around. As with any major bowel resection, there are risks/complications – either specifically related to the bowel, either a leak or a bleed at the join (anastomosis), or generally related to an operation, such as wound infection, chest infection, leg and lung clots (deep venous thrombosis and pulmonary emboli). The surgery can also be associated with exacerbations of other medical conditions such as problems with your heart and lungs, diabetes, blood pressure and kidney problems.

 It is important to discuss the specifics of your operation with your surgeon.

Left Hemicolectomy

Left hemicolectomy is the surgical removal of the left side of the large bowel (see the first figure below); sigmoid colectomy is the surgical removal of the sigmoid colon. These operations are mostly performed for cancers of the left colon and sigmoid colon.

See Right Hemicolectomy for other information about bowel resection.

Left colectomy.

Total Colectomy

Colectomy is a surgical procedure to remove the majority of the colon. Total Colectomy may be necessary to treat or prevent diseases and conditions that affect your colon, also known as the large intestine or large bowel. Such conditions include –

  • Bleeding that can’t be controlled.Severe bleeding from the colon may require surgery to remove the affected portion of the colon.
  • Bowel obstruction.A blocked colon is an emergency that may require total or partial colectomy, depending on the site of the obstruction and any secondary damage due to distension of or loss of blood supply to the colon.
  • Colon cancer.Early-stage cancers may require only a smaller section of the colon to be removed during colectomy. Multiple cancers, cancers presenting at a later stage and cancers presenting as an obstruction may require more of the colon to be removed.
  • Crohn’s disease.If medications aren’t helping you, removing the affected part of your colon may offer temporary relief from signs and symptoms. Colectomy may also be an option if precancerous changes are found during a test to examine the colon (colonoscopy).
  • Ulcerative colitis.Your doctor may recommend total colectomy if medications aren’t helping to control your signs and symptoms. Colectomy may also be an option if precancerous changes are found during a colonoscopy.
  • Your doctor may recommend surgery to remove the affected portion of the colon if your diverticulitis recurs or if you experience complications of diverticulitis.
  • Preventive surgery.If you have a very high risk of colon cancer due to the formation of multiple precancerous colon polyps, you may choose to undergo total colectomy to prevent cancer in the future. Colectomy may also be an option for people with inherited genetic conditions that increase colon cancer risk, such as familial adenomatous polyposis or Lynch syndrome.

In the elective situation, the type of surgery considered best for you and your clinical circumstances will be discussed, along with any options. It may obviously be a little more difficult to have this discussion at length in the emergency situation.

Hartman’s Procedure

rectosigmoidectomyHartmann’s operation or Hartmann’s procedure is the surgical removal of part of the rectum and the sigmoid colon with closure of the anorectal stump and formation of an end colostomy. It is used to treat bowel cancer or other complicated inflammatory conditions in the rectosigmoid region, most commonly in the urgent situation, when it is not deemed safe to perform an anastomosis (make a join in the bowel).  More rarely it is used palliatively patients with advanced colorectal tumours.

Anterior resection

This is an operation to remove all or part of the rectum and usually part of the sigmoid colon. It is most commonly performed for bowel cancer. It can be performed “open” with an incision in the abdominal wall or laparoscopically, commonly called “key hole surgery”.

After the segment of bowel is removed, along with its blood supply, the two ends of bowel are joined together (anastomosed) with stitches or stapling devices. This requires the anal canal to be preserved, and the bowel upstream to be able to be brought down to join the rectum or anus without compromising the blood supply.

It is uncommon to require a bag or stoma in association with a high anterior resection, which involves removing the upper part of the rectum. If it is required it is usually only when there is technical concern about the anastomosis or there are patient co-morbidities that make an unprotected anastomosis unnecessarily risky.

It is more common to require a bag or stoma in association with a low or very low anterior resection, which involves removing most or all of the rectum. The bag or stoma is usually a loop ileostomy to divert faecal matter from the downstream bowel join.

Anterior resection is a major surgical procedure. The most concerning surgical risk is a leak from the anastomosis, which can occur in between 10-20% of patients especially if the join is “ultra” low and the pelvis has been preoperatively irradiated. It is also attended by the other common surgical risks, such as wound infections as the bowel needs to be opened during the procedure, and medical risks such as heart and lung problems, fluid balance and kidney issues, as well as calf clots (DVT’s) which can travel to the lungs (pulmonary emboli).

Pain relief is well organised after the procedure. Fluids and return to a normal diet are determined by your surgeon’s usual protocol and your individual circumstances.

Your surgeon will discuss the particulars of your surgery with you preoperatively.

Abdominoperoneal resection

Abdominoperineal resection (APR) is an operation in which a surgeon removes the anus, rectum and part of the sigmoid colon using incisions in your abdomen and between your buttocks (perineum). It is most commonly performed for rectal and anal cancers, in particular in the situation where the rectal cancer being removed is very low in the rectum and it is not possible to get an adequate clearance of the tumour when removing and preserving enough sphincter muscle to maintain continence.

At the completion of the surgery, the end of the residual colon will be brought to the skin on the left hand side of the abdomen, allowing faecal material to drain in to a bag. This arrangement is known as a colostomy or stoma. Unlike the anus, the stoma has no sphincter muscles. Faecal material will thus drain in to the bag as the colon contracts.

Abdominoperineal resection is major surgery and will require the patient to be in hospital for around a week postoperatively to recover, and learn the basics of managing their colostomy.

Laparoscopic Surgery

Laparoscopic (keyhole or minimally invasive) surgery on the colon and rectum offers significant advantages over open surgery for many patients. Using small incisions and advanced video technology,  laparoscopic surgeons are able to perform a wide range of complex colorectal surgical procedures for conditions like colorectal cancer, diverticular disease, inflammatory bowel disease and rectal prolapse. Research has demonstrated that patients having laparoscopic procedures have less pain, smaller incisions, faster return of intestinal function, shorter hospital stays and faster return to work. Some of these benefits are only very modest, in comparison to some other laparoscopic procedures where the advantages are far greater. Laparoscopic surgery achieves equivalent cancer outcomes and has fewer complications overall than traditional open surgery.

Colostomy and Ileostomy

When the large bowel or colon is brought through the abdominal wall and empties into a bag, this is called a colostomy. A colostomy may be temporary or permanent, depending on the condition it was made for and the circumstances under which it was made.

Patients with a colostomy can usually eat and drink normally. The colostomy works periodically during the day, and usually produces a solid or formed stool. Depending on the type of appliance used to manage the colostomy, sometimes the bag is then emptied and if another type of appliance, the bag is then removed and discarded and a new bag applied. Modern appliances effectively absorb odour and vent gas. Leakage beneath the appliances are relatively uncommon when the appropriate appliances are used.Patients with colostomies can work, exercise, swim and have normal relationships.

Problems with stoma prolapse, parastomal hernias, retraction, stenosis or bleeding can occur and may require corrective surgery.

Stomas can also be made with small intestine. Most commonly this is part of the small intestine known as the ileum, thus the stoma is an ileostomy. They are managed in a similar way to colostomies in that the fluid that drains from them is caught in a bag attached to the skin.

Ileostomies can be fashioned in different ways depending on their use and whether they are temporary or permanent. Permanent ileostomies are most commonly ‘end’ ileostomies and thus only have one ‘hole’ or ‘lumen’ at the skin opening. Temporary ileostomies are often ‘loop’ ileostomies and have two lumens at the skin.

Because the effluent from ileostomies is liquid and is digestive, they can sometimes be a little more tricky to manage than colostomies, where the effluent is usually formed. Ileostomies are also more likely to produce dietary modifications, allowing the fluid volume coming from the stoma to be kept to a reasonable volume.

Independent of which type of stoma is formed, whilst still in hospital, you will meet one of the highly trained, skilled nurses who specialise in looking after stomas – stomatherapists. The stomatherapist will teach you how to look after your stoma and select and organise the appropriate appliances for you. They will often also visit you at home shortly after you leave hospital, to make sure you are coping away from the hospital environment. They will also facilitate your joining of the Stoma Society, so that you will always have supplies to manage your stoma.

Haemorrhoidectomy

Most haemorrhoid related symptoms can be treated without surgery, with many patients benefiting from attention being paid to their diet and toilet or defecatory habits. The most common procedures for haemorrhoids if required are rubber band ligation or injection sclerotherapy.

When external haemorrhoids are large and/or when internal haemorrhoids are large and prolapse and cannot be reduced, or repeated minor procedures have failed to improve symptoms, excision of haemorrhoidal tissue known as a haemorrhoidectomy may be required, usually under a general anaesthetic.

If performed in conjunction with a colonoscopy you will have a full bowel preparation before surgery, and if performed alone you may have an enema prior to surgery.

The type of haemorrhoidectomy you will have depends on the size and arrangement of the haemorrhoids in your perianal region. Haemorrhoidectomy can be accompanied by significant discomfort, especially when you open your bowels. Local nerve blocks will control this initially post-op but most patients require pain relief in the first post-op days. The pain can last for one to two weeks following haemorrhoidectomy. You will be given specific instructions following the surgery about caring for your wound(s) but they usually include regular warm salt or sitz baths, avoiding hard wiping of the area, the use of perianal pads, taking of stool softeners, pain medicine, fibre supplements and possibly a laxative.

It may take up to 4-6 weeks for your wounds to heal after haemorrhoid surgery but most patients are back at work and other normal activities during that time.

Haemorrhoid Banding

Banding of haemorrhoids is a common procedure for moderate sized haemorrhoids. The procedure is often combined with either a colonoscopy or a flexible sigmoidoscopy to ensure that there are no other abnormalities to account for the bleeding, further along the bowel.

The band is typically applied at the top part of the haemorrhoid above the anal canal. The bands work by cutting off blood supply to the haemorrhoidal tissue and this process also draws the haemorrhoid inward reducing the risk of it further prolapsing. The healing process at the banding site also helps to attach residual haemorrhoid tissue to the underlying muscle to prevent or decrease further prolapse and bleeding. Multiple bands may be required to treat the haemorrhoids. Following banding, there is often a sensation of rectal fullness, which can produce some discomfort and an urge to defaecate. These sensations usually pass after a couple of days.

Most banding is uncomplicated but minor bleeding can occur in the first week after the banding, usually when the haemorrhoids separate from the anal canal. Repeat banding  may also be required in some patients.

Fistula in ano

A fistula in ano is an abnormal tract running from the anus to the skin, that usually develops after an infection in one of the anal glands. Treatment of a fistula depends on the anatomy of the tract – specifically how much of the anal sphincter is involved in the tract. If only a small amount of the sphincter seems to be involved, and treatment is unlikely to effect continence, then a simple “fistulotomy” can be performed. This involves placing a probe through the fistula then incising on to this probe, allowing the tract to be “laid open”. More complex fistulae may need more complex and sometimes multiple procedures involving drains, Setons, plugs, flaps, lifts and rarely, stomas. Before embarking on a of course of treatment, complex fistulae need to be thoroughly discussed with your surgeon.

Dressing and otherwise caring for you fistula wound is usually quite straightforward. You will be given specific instructions on the day of surgery, but they usually include regular warm salt or sitz baths, avoiding hard wiping of the area, the use of perianal pads, and taking of stool softeners, pain medicine, fibre supplements and possibly a laxative.

Perianal abcess

Drainage of perianal abscess is usually a straightforward procedure to treat a perianal abscess. The procedure is usually performed under a general anaesthetic, as the perianal region can be acutely sensitive, and also to allow the surgeon to assess the extent of the infective process. In most situations, a single incision is needed to drain the abscess. Once the pus is drained, the abscess cavity is usually washed out and dressed with a simple wound dressing.

After the procedure, the surgical wound will need ongoing wound care. Your doctor will give you further instructions about this wound care before you leave hospital.

Do you have any questions?