Rectal Cancer Surgery: Everything You Need To Know

Rectal cancer is generally treated with surgery. Although both rectal cancer and colon cancer are often classified under the umbrella term of colorectal cancer, each cancer requires a different approach to surgery.

Rectal surgery is often more complicated than colon surgery because the rectum is squeezed into the pelvis and sits very close to important neighboring organs and structures. The rectum is also adjacent to the anus (the muscular sphincter that regulates stool evacuation).

The types of surgery for rectal cancer

There are many different surgical procedures used to treat rectal cancer. Your colorectal surgeon will help decide the right surgery for you, depending on the stage of your rectal cancer and its location in the rectum.

Before surgery, your colorectal surgeon will discuss the options with you. Sometimes it is also necessary to have chemotherapy or radiation therapy before or after surgery. In this case, an oncologist or radiation therapist may also become involved.

Polypectomy and local excision

This procedure is used for early-stage tumors that have not spread through the wall of the rectum. This type of surgery can be done during a colonoscopy. You will not have to have an incision through your abdomen, as it is done internally during your colonoscopy.

A polypectomy is a procedure used to remove a polyp, a mushroom-like structure with a stalk. It is common for rectal cancers to present as polyps. In a polypectomy, the tumor is removed at the base of the stalk.

Local excision is the procedure used to remove a tumor that is either flat or has grown into the lining of the rectum wall. This is a slightly more invasive procedure than a polypectomy, as part of the inside of the rectal wall needs to be cut away.

Because both procedures are minimally invasive surgeries, you may only need to spend a day or two in the hospital, and recovery is unlikely to take longer than a couple of days.

Transanal Excision (TAE)

Like a polypectomy and local excision, TAE is minimally invasive surgery. This means it can be done internally and doesn’t require a large incision through the abdominal wall. You may have a TAE if the site of the rectal cancer is located relatively close to the anus and extends through the wall of the rectum.

In a TAE procedure, a colorectal surgeon cuts through all layers of the rectal wall to remove cancer and some surrounding non-cancerous rectal tissue. The hole in the rectal wall is then closed. Lymph nodes cannot be removed during TAE, so you may need radiation therapy after this procedure.

As this surgery is minimally invasive, you may only need to spend a day or two in the hospital, and recovery is likely only to take a few days.

Transanal Endoscopic Surgery (TES)

A TES procedure is similar to TAE but performed on tumors higher up in the rectum and further away from the anus. This type of surgery is very precise and requires specialized skills and equipment, so it is only performed in certain centers.

As TES is a similarly minimally invasive surgery, you may only spend a day or two in the hospital and recover after several days.

Low Anterior Resection (LAR)

A LAR procedure removes stage I, II, and III tumors that have spread locally beyond the rectum, either into adjacent structures or local lymph nodes.

During this operation, the part of your rectum containing the tumor is removed. The lower part of your colon (above where the tumor was removed) is then attached to the remaining part of your rectum, so your bowels move in the usual way.

You will not require a permanent colostomy. However, sometimes the colon can only be re-attached to the remaining rectum at a later stage, so you may have to have a temporary colostomy for a short period after this surgery.

If you have had radiation or chemotherapy before your LAR, you may need an ileostomy temporarily until your colon and rectum heal.

Your LAR will be done under general anesthesia through several small cuts in your abdomen. Rectal cancer and the rim of normal tissue around cancer will be removed, as well as nearby lymph nodes and other tissue around the rectum.

As this procedure is considered an invasive surgery, you may need to spend a few days in the hospital after the procedure so that your surgeon can monitor your recovery. 

Recovery at home will take anywhere between three and six weeks, depending on how complex the surgery was and what your general health is like.

Proctectomy with colo-anal anastomosis

A proctectomy is when the entire rectum is removed. This is necessary for larger, more advanced-stage rectal cancers that involve the middle and lower thirds of the rectum.

During this procedure, after removing your rectum and all lymph nodes near your rectum, the colon will be re-attached directly to your anus (called a colo-anal anastomosis). This means that you will not require a colostomy and will be able to have normal bowel movements.

A proctectomy and colo-anal anastomosis will be done under general anesthesia and will require incisions through the abdomen. You may also need a temporary ileostomy to allow the join between the colon and anus to heal.

Because this type of surgery is an invasive procedure, you may need to spend a few days in hospital afterward so that your surgeon can monitor your recovery. You will be able to be discharged once your bowels are functioning properly (you’ve passed gas or stool) and you no longer require IV fluids to maintain hydration.  

Recovery at home will take anywhere between three to six weeks, depending on the complexity of the surgery and your general state of health.

Abdominoperineal resection (APR)

The APR procedure is necessary if your rectal cancer also involves the anus. The surgeon will make a cut or incision in the skin of the abdomen and another in the skin around the anus. This allows the surgeon to remove your rectum, anus, and the surrounding tissue, including the sphincter muscle. Because your anus has been removed, you will need a permanent colostomy to allow stool to pass since you will not be able to have natural bowel movements after the operation.

You will need a general anesthetic for an APR as it is a complex operation. You will most likely spend several days in the hospital after an APR, depending on the complexity of the surgery and your general state of health. Recovery time at home can range from three weeks to two months.

Pelvic exenteration

If your rectal cancer has spread to any of the organs adjacent to your rectum, such as your prostate (if you’re male), uterus (if you’re female), or bladder, you may require a pelvic exenteration. This involves the removal of your anus, which means you will need a permanent colostomy after this procedure.

A pelvic exenteration is a major operation that requires general anesthesia. It can typically take a few months to recover after the surgery.

Diverting colostomy

This procedure is performed when the tumor completely obstructs your rectum. The surgeon will divert a section of the colon above the rectum to the surface of the skin to create a colostomy. The stool is then able to be evacuated through the colostomy. This gives you time to have radiation therapy or chemotherapy to shrink your tumor enough to allow for surgery. If your tumor is determined to be inoperable, the diverting colostomy helps with the symptoms of blockage.

Surgery for rectal cancer spread

If your cancer has spread to other organs, you may be able to have surgery to remove the metastasized tumors. This would usually only be done if rectal cancer itself is small enough to be completely surgically removed. The type of surgery required will depend on the organs involved, the site and number of the metastases, and their size.

The success of rectal cancer surgery

The success of your rectal cancer surgery depends on the location and stage of cancer in your body. Surgery can be completely curative if you have early cancer that has not spread and can be fully excised.

If your cancer has spread locally, surgery can still provide a cure, especially when combined with radiation therapy. However, if your cancer is very advanced, surgery may be performed to alleviate your symptoms only as it may not be possible to cure cancer.

Preparing for rectal cancer surgery

Your colorectal surgeon will advise you on how to prepare for your rectal cancer surgery. The type of preparation required will depend on the type of surgery you are having and will likely be different for a colonoscopy or an abdominoperineal resection compared to other surgeries. 

It is important that you follow the advice given to you to minimize any complications from the surgery. Advice you may be given could include:

• Consume a diet of clear liquids for a specified period before surgery

• Fleet enemas the day before surgery

• You may be required to drink bowel prep before your procedure. This is a laxative that clears residual waste from your colon and rectum to give your surgeon optimal visibility of the area during surgery.

What to expect after rectal surgery

Your recovery after surgery will depend on the type of surgery you have had. Recovery time from a colonoscopy and local excision will be quick and likely not require any special after-procedure care, while recovery from more complex procedures will be longer and require post-operative care.

You may also have lasting side effects from your rectal cancer surgery. These may include a permanent colostomy, a change in bowel patterns, sexual and bladder dysfunction (if the surgery involved organs or structures surrounding the rectum), and mental health issues, such as depression and anxiety. 

If you are impacted by any side effects following your rectal cancer surgery, it is important to speak to your surgeon for medical advice on managing the symptoms. It is also recommended to reach out to support groups that can help you learn to live with your new normal with those in a similar position to you.

The lowdown

Surgery for rectal cancer ranges from minimally invasive procedures to complex, major surgeries. The type of surgery you require will depend on the stage of your rectal cancer and where it is located (higher up in the rectum versus lower down toward the anus).

In many cases, particularly if you have lower-stage rectal cancer, surgery can cure you. If surgery alone is not curative, it may be combined with radiation therapy or chemotherapy for better outcomes. Surgery may also be performed to alleviate symptoms from cancer, such as if you have later stage rectal cancer.

Recovery time from your rectal cancer surgery can range from a few days (for a less invasive procedure like a polypectomy) to multiple months (for a more complex, invasive procedure such as abdominoperineal resection).

You may not experience any side effects after surgery, depending on the type of rectal cancer and the surgery you have undergone. However, there may be lasting side effects that can impact your life post-surgery in various ways, in which case it is important to speak to your doctor about the ongoing support you can access.