Surgery for Rectal Cancer

Surgery is usually the main treatment for rectal cancer, although radiation and chemotherapy will often be given before or after surgery. The type of surgery used depends on the stage (extent) of the cancer, where it is, and the goal of the surgery.

Polypectomy and local excision

These procedures can be used to remove superficial cancers or polyps. They are done with instruments inserted through the anus (often during a colonoscopy), without cutting into the skin of the abdomen.

  • For a polypectomy, the cancer is removed as part of the polyp, which is cut at its stalk (the area that resembles the stem of a mushroom). This is usually done by passing a wire loop through the colonoscope to cut the polyp from the wall of the rectum with an electric current.
  • A local excision is a slightly more extensive procedure that can be used to remove superficial cancers and a small amount of nearby tissue from the rectum wall.

Local transanal resection (full thickness resection)

As with polypectomy and local excision, local transanal resection (also known as transanal excision) is done with instruments inserted through the anus, without making an opening in the skin of the abdomen.

In this operation, the surgeon cuts through all layers of the rectal wall to remove cancer as well as some surrounding normal rectal tissue, and then closes the hole in the rectal wall. This procedure can be used to remove some early stage I rectal cancers that are relatively small and not too far from the anus. It is usually done with local anesthesia (numbing medicine) – you are not asleep during the operation.

Since lymph nodes are not removed during this procedure, if the tumor has grown too deep, radiation with or without chemotherapy may be recommended after surgery. 

Transanal endoscopic microsurgery (TEM)

This operation can sometimes be used for early stage I cancers that are higher in the rectum than could be reached using the standard transanal resection (see above). A specially designed magnifying scope is inserted through the anus and into the rectum, allowing the surgeon to do a transanal resection with great precision and accuracy. This operation requires special equipment and surgeons with special training and experience, so it is only done at certain centers.

Low anterior resection (LAR)

Some stage I rectal cancers and most stage II or III cancers in the upper part of the rectum (close to where it connects with the colon) can be removed by low anterior resection (LAR). In this operation, the part of the rectum containing the tumor is removed. The colon is then attached to the remaining part of the rectum (either right away or sometime later) so that you will move your bowels in the usual way.

A low anterior resection is done with general anesthesia, which puts you into a deep sleep. The surgeon makes an incision (or several small incisions) in the abdomen. Then the surgeon removes the cancer and a margin of normal tissue on either side of the cancer, along with nearby lymph nodes and other tissues around the rectum.

The colon is then reattached to the remaining rectum so that a permanent colostomy is not needed. If radiation and chemotherapy have been given before surgery, it is common for a temporary ileostomy to be made (where the end of the ileum, the last part of the small intestine, is connected to a hole in the abdominal wall). This gives the rectal area some time to heal from treatment before food matter moves through it again. Usually the ileostomy can be reversed (the intestines reconnected) about 8 weeks later.

You will probably spend several days in the hospital after a low anterior resection, depending on how the surgery was done and your overall health. You might need 3 to 6 weeks to recover at home.

Proctectomy with colo-anal anastomosis

Some stage I and most stage II and III rectal cancers in the middle and lower third of the rectum require removing the entire rectum (proctectomy). The rectum has to be removed to do a total mesorectal excision (TME), which is needed to remove all of the lymph nodes near the rectum. The colon is then connected to the anus (colo-anal anastomosis) so that you will still move your bowels in the usual way.

Sometimes when a colo-anal anastomosis is done, a small pouch is made by doubling back a short segment of colon (colonic J-pouch) or by enlarging a segment (coloplasty). This small reservoir of colon then functions as a storage space for fecal matter like the rectum did before surgery. When special techniques are needed to avoid a permanent colostomy, you may need to have a temporary ileostomy (where the end of the ileum, the last part of the small intestine, is connected to a hole in the abdominal wall) for about 8 weeks while the bowel heals. A second operation is then done to reconnect the intestines and close the ileostomy opening.

You will have general anesthesia (you are asleep) for this operation. You will probably spend several days in the hospital after surgery, depending on how it was done and your overall health. You might need 3 to 6 weeks recovery time at home.

Abdominoperineal resection (APR)

This operation is more extensive than a low anterior resection. It can be used to treat some stage I cancers and many stage II or III cancers in the lower part of the rectum (the part nearest to the anus), especially if the cancer is growing into the sphincter muscle (the muscle that keeps the anus closed and prevents stool leakage).

Here, the surgeon makes an incision (or several small incisions) in the abdomen, and another in the area around the anus. This incision allows the surgeon to remove the anus and the tissues surrounding it, including the sphincter muscle. Because the anus is removed, you will need a permanent colostomy (the end of the colon is connected to a hole in the abdominal wall) to allow stool to leave the body.

You will have general anesthesia ( you are asleep) for this operation. You will probably spend several days in the hospital after an APR, depending on how the surgery is done and your overall health. Recovery time at home may be 3 to 6 weeks.

Pelvic exenteration

If the rectal cancer is growing into nearby organs, a pelvic exenteration may be recommended. This is an extensive operation. The surgeon will remove the rectum as well as nearby organs such as the bladder, prostate (in men), or uterus (in women) if the cancer has spread to these organs.

You will need a colostomy after pelvic exenteration. If the bladder is removed, you will also need a urostomy (an opening in the front of the abdomen where urine leaves the body and is held in a portable pouch).

Diverting colostomy

Some patients have rectal cancers that have spread but also have tumors blocking the rectum. For patients with this problem, sometimes surgery is done to relieve the blockage without removing the part of the rectum containing the cancer. Instead, the colon is cut above the tumor and attached to a stoma (an opening in the skin of the abdomen) to allow body wastes out. This is known as a diverting colostomy. It can often help the patient recover enough to start other treatments (such as chemotherapy).

Surgery for rectal cancer spread

If the cancer has spread to just one or a few spots in the lungs or liver (and nowhere else), surgery may be used to remove it. This is generally done only if the main cancer in the rectum is being removed as well (or was already removed). Depending on the extent of the disease, this might help you live longer, or it may even cure you. Deciding if surgery is an option to remove areas of cancer spread depends on their size, number, and location.

Side effects of rectal surgery

Possible risks and side effects of surgery depend on several factors, including the extent of the operation and a person’s general health before surgery. Problems during or shortly after the operation can include bleeding from the surgery, infections at the surgery site, and blood clots in the legs. 

When you wake up after surgery, you will have some pain and probably will need pain medicines for a few days. For the first couple of days, you may not be able to eat or you may be allowed limited liquids, as the colon needs some time to recover. Most patients are able to eat solid food again in a few days.

Rarely, the new connections between the ends of the intestine may not hold together completely and may leak, which can lead to infection and might require further surgery. It’s also possible that the incision in the abdomen might become an open wound. After the surgery, you might develop scar tissue in the abdomen that can cause organs or tissues to stick together. These are called adhesions. In some cases, adhesions can block the bowel, and you will need further surgery.

Colostomy or ileostomy

Some people need a temporary or permanent colostomy (or ileostomy) after surgery. This may take some time to get used to and may require some lifestyle adjustments. If you have a colostomy or ileostomy, you will need to learn how to manage it. Specially trained ostomy nurses or enterostomal therapists can help you with this. They will usually see you in the hospital before your operation to discuss the ostomy and to mark a site for the opening. After your surgery they may come to your house or an outpatient setting to give you more training. For more information, see Colostomy Guide and Ileostomy Guide .

Sexual function and fertility

If you are a man, an AP resection (APR) may stop your erections or ability to reach orgasm. In other cases, your pleasure at orgasm may become less intense. Normal aging may cause some of these changes, but they may be made worse by the surgery.

An APR can also affect fertility. Talk with your doctor if you think you might want to father a child in the future, as there may still be ways to do this. For more on this topic, see Fertility and Men With Cancer.

If you are a woman, rectal surgery (except pelvic exenteration) usually does not cause any loss of sexual function. Abdominal adhesions (scar tissue) may sometimes cause pain or discomfort during sex. If your uterus is removed, you will not be able to get pregnant.

A colostomy can have an impact on body image and sexual comfort level in both men and women. While it may require some adjustments, it should not keep you from having an enjoyable sex life.

For more on dealing with the sexual impact of cancer surgery, see Sexuality for the Man With Cancer and Sexuality for the Woman With Cancer.

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master’s-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

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Last Medical Review: January 15, 2017 Last Revised: March 2, 2017

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