Colorectal Cancer: Surgery

Pictured: José Guillem José G. Guillem is one of Memorial Sloan Kettering's colorectal surgeons with special expertise in preserving the anal sphincter as well as bladder and sexual function after rectal cancer surgery.

Surgery is the most common treatment for many stages of rectal cancer. In cases where the cancer is found early, removing the tumor surgically can lead to a cure.

Memorial Sloan Kettering surgeons can often remove small cancers in the rectum that have not grown through the wall of the bowel. This approach is similar to a lumpectomy for breast cancer, in that as little as possible of the surrounding healthy tissue is removed. Some cancers that have grown through the wall of the rectum or involve the lymph nodes may require more-extensive surgery.

Treatment for rectal cancer requires a surgeon who is highly experienced. Surgery for rectal cancer is often more complex than surgery for colon cancer, due to the narrow confines of the bony pelvis. This area contains the nerves that control sexual and bladder function, and so care must be taken to avoid damaging them as much as possible. The rectum also plays a critical role in bowel function.

In some cases, particularly for larger rectal tumors, chemotherapy and radiation therapy are used before an operation to shrink the tumor. At Memorial Sloan Kettering, rectal surgeons work closely with other members of the colorectal disease management team to determine the combination of treatments that will give you the best result.

Improving Rectal Surgery

At Memorial Sloan Kettering, we are continually developing and refining new techniques to preserve normal function in people who have had rectal surgery.

In the past, patients who underwent rectal surgery would often require a permanent colostomy, an operation in which one end of the large intestine is brought out through the abdominal wall. Wastes moving through the intestine drain into a pouch attached to the abdomen.

At Memorial Sloan Kettering, improvements in surgical technique now enable 90 percent of our patients undergoing rectal surgery to avoid the need for a permanent colostomy.

Memorial Sloan Kettering surgeons also pioneered a technique that allows the delicate removal of all cancerous tissue in and around the rectum but carefully avoids severing the nerves involved in sexual and urinary function. Such nerve-preserving surgery is the standard of care at Memorial Sloan Kettering.

In some patients, such as men with large prostate glands, these techniques may not be feasible, and a procedure called coloanal reconstruction is needed. In this approach, the surgeon removes the rectum and then connects the upper colon directly to the anus.

In select cases, a colonic reservoir can be created to improve bowel function after the rectum is removed. Memorial Sloan Kettering surgeons  can construct an internal colon pouch (called the J-Pouch) where they loop two sections of the lower colon upon itself and open up the wall between them to create a larger reservoir for storing wastes, essentially replacing the rectum.

Minimally Invasive Techniques

Minimally invasive surgery is a surgical procedure performed through small incisions — usually made in the abdominal wall — which results in the least possible harm to organs and surrounding tissue. Minimally invasive surgery has a number of potential benefits for patients, including fewer complications, less blood loss, a shorter hospital stay, and quicker recovery than conventional open surgery.

Surgeons at Memorial Sloan Kettering are investigating two types of minimally invasive surgery for rectal cancer: laparoscopic surgery and robotic surgery.

Laparoscopic Surgery

Surgeons at Memorial Sloan Kettering have begun to perform some rectal surgeries laparoscopically. Laparoscopic surgery is a type of minimally invasive surgery in which a thin, lighted tube with a camera at its tip (called a laparoscope) is inserted through a small incision in the abdomen. The camera projects a magnified, high-definition image of the surgical area onto a screen. Using the image as a guide, the surgeon uses specialized surgical instruments to perform the surgery.

Because laparoscopy requires much smaller incisions than traditional open surgery, patients typically undergo less trauma, have faster recoveries, and return to their usual activities sooner.

Our surgeons are helping to lead national clinical trials to assess this approach in rectal surgery. Early studies of minimally invasive rectal resection for cancer indicate that the procedure is safe and feasible; however, more often than not, it cannot be performed laparoscopically in its entirety, and an incision is required low in the pelvis to complete the surgery.

Robotic Surgery for Rectal Cancer

Specially trained surgeons at Memorial Sloan Kettering have also begun investigating the use of an advanced robotic device — called the daVinci® Surgical System — to remove rectal cancer. During robotic surgery, the surgeon sits at a console that has hand, finger, and foot controls. The robot precisely copies every movement while the surgeon views the operation on a screen.

The robotic arms have multiple joints and can maneuver with great dexterity in the pelvis. The robot also increases the precision of the surgeon's motions by scaling down each movement by half or even three-quarters. This allows the surgeon to make much finer movements in tight spaces than would be possible in open or traditional laparoscopic surgery. The finer movements help with nerve preservation and the maintenance of normal bowel, urinary, and sexual function.

Robotic devices have been used successfully to treat other types of cancer — such as prostate cancer and gynecological cancers — but their use to treat rectal cancer is still in an early stage and is only appropriate in specific situations.

Transanal Endoscopic Microsurgery

For selected patients with localized rectal cancer, Memorial Sloan Kettering Cancer Center offers a surgical procedure known as transanal endoscopic microsurgery (TEM). This approach minimizes treatment-related complications, reduces recovery time, and spares nearby nerves associated with urinary control and sexual function. Perhaps most important, patients treated with TEM do not require a colostomy.

In TEM, the surgeon inserts a scope into the anus and is able to remove early-stage rectal cancers less invasively. This approach is especially suitable for patients who are elderly, who have other medical conditions that would make it difficult to cope with the strain of other surgical approaches, or who prefer not to undergo a standard abdominal operation.

Conducted under either general or spinal anesthesia, a typical TEM procedure for rectal cancer takes about two hours, compared with the three to four hours that a standard abdominal procedure may last. Patients receiving TEM can leave the hospital soon after the procedure, whereas the standard abdominal procedure requires a weeklong postsurgery hospital stay.

Memorial Sloan Kettering is the most experienced institution in the tri-state area offering TEM. The procedure has been performed at Memorial Sloan Kettering since 2004 .

Surgery and Advanced Rectal Cancer

In some cases, it may not be in your best interest to have a rectal tumor removed surgically. A 2009 study by Memorial Sloan Kettering researchers showed that a large majority of patients with advanced rectal cancer that has spread to other organs don't require immediate surgery to remove the primary tumor in the rectum.1

As long as the tumor is not causing obstruction, perforation, or bleeding, you may be best treated with chemotherapy. By moving straight to chemotherapy, you may also be able to avoid the risk of surgical complications and start treatment for the disease throughout the entire body without delay.

1Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment. Poultsides GA, Servais EL, Saltz LB, Patil S, Kemeny NE, Guillem JG, Weiser M, Temple LK, Wong WD, Paty PB. J Clin Oncol. 2009 Jul 10;27(20):3379-84. Epub 2009 Jun 1. [PubMed Abstract]