This guide will help you get ready for your abdominal perineal resection (APR) surgery at Memorial Sloan Kettering (MSK). It will also help you understand what to expect during your recovery.
Read through this guide at least once before your surgery and use it as a reference in the days leading up to your surgery.
Bring this guide with you every time you come to MSK, including the day of your surgery. You and your healthcare team will refer to it throughout your care.
About Your Surgery
Understanding how your digestive system works can be helpful as you get ready for and recover from your surgery. Your digestive system is made up of organs that break down food, absorb nutrients, and remove waste from your body. They include your mouth, esophagus (food pipe), stomach, small intestine, colon (large intestine), rectum, and anus (see Figure 1).
After your food has been chewed and swallowed, it moves into your esophagus. This is a long, muscular tube that serves as a passageway for food as it travels from your mouth into your stomach. Once the food enters your stomach, it mixes with stomach acids. These acids begin to digest (break down) the food.
When the food leaves your stomach, it moves into your small intestine. There, it continues to be digested, and many nutrients are absorbed. Anything that isn’t absorbed is called waste.
The waste then moves into your colon, where some water is reabsorbed (taken back) into your body. The remaining waste enters the end of your colon, known as the rectum. Your rectum serves as a holding area for the waste until it leaves your body through your anus.
APR is a surgery that’s done to treat anal or rectal cancer (see Figure 1). To remove the cancer, your surgeon will remove all of the following:
- The lower part of your colon
- Your rectum
- Your anus
An APR can be done using different techniques. Your surgeon will talk with you about which options are right for you. Depending on what type of surgery you have, your surgeon will make 1 or more incisions (surgical cuts) in your abdomen (belly).
- When 1 long incision is made on your abdomen, this is called open surgery.
- When several small incisions are made on your abdomen, this is called minimally invasive surgery. Small surgical tools and a video camera are inserted into the incisions to remove the cancer. Some surgeons use a robotic device to assist with the surgery.
Your surgeon will also make 1 incision in your perineal area. This is the area between your vagina and anus or scrotum and anus.
When your surgeon removes your rectum and anus, a large empty space will be left in between your buttocks. The space will be closed by sutures (stitches). While the space is healing, there will be restrictions on how you sit, lie down, and do some of your usual activities. Your doctor or nurse will discuss these restrictions with you. When the area has healed, it won’t be noticeable to other people and you will be able to go about your daily activities.
Because your rectum and anus will be removed, you will need a new place for your stool (poop) to leave your body. During your surgery, the lower end of your colon will be brought outside your body through the skin on your abdomen. This is called a colostomy.
You will see the lining of your colon on the outside of your abdomen. This is called a stoma. Your stoma will be pink or red and look shiny and moist. Colostomy stomas are usually placed on the lower left side of the abdomen, about 2 inches away from the belly button (see Figure 2).
After your surgery, your stool will leave your body from your stoma. You will wear a colostomy pouch over your stoma. This pouch will collect your gas and stool. A wound, ostomy, continence (WOC) nurse will teach you how to change your pouch and care for your stoma. No one will know you have a colostomy unless you tell them.Back to top
Before Your Surgery
Meet With a Wound, Ostomy, Continence (WOC) Nurse
You will meet with a WOC nurse before your surgery. A WOC nurse is a registered nurse who specializes in wound and ostomy care. They will teach you and your family how to care for your new colostomy and help you become more independent. A WOC nurse will also show you a colostomy pouch so that you can become familiar with it.
A WOC nurse will help your surgeon choose the best placement for your stoma before your surgery. But your surgeon will decide on the final location during your surgery. A WOC nurse will also work with you and your family, doctor, and nurses after your surgery to help with your recovery.
Be sure to ask the WOC nurse any questions you or your family may have about your colostomy.
Buy Bowel Preparation Supplies
You will need to do a bowel preparation before your surgery. Your doctor will give you a prescription for antibiotics to take as part of your bowel preparation. You will also need to buy the following supplies:
- 1 (238-gram) bottle of polyethylene glycol (MiraLAX®). You can get this from your local pharmacy. You don’t need a prescription.
- 1 (64-ounce) bottle of a clear liquid. For examples of clear liquids, read the “Follow a Clear Liquid Diet” section.
Buy Clear Liquids
You will need to follow a clear liquid diet before your surgery. Now a good time to buy your supplies.
For a list of clear liquids you can drink, read the section “Follow a Clear Liquid Diet.”
Start Your Bowel Preparation
Start your bowel preparation 1 day before your surgery.
On the morning of the day before your surgery, mix all 238 grams of MiraLAX with the 64 ounces of clear liquid until the MiraLAX powder dissolves. Once the MiraLAX is dissolved, you can put the mixture in the refrigerator, if you prefer.
At 5:00 pm on the day before your surgery, start drinking the MiraLAX mixture. The MiraLAX will cause frequent bowel movements, so make sure you’re near a bathroom.
- Drink 1 (8-ounce) glass of the mixture every 15 minutes until the container is empty.
- When you finish the MiraLAX mixture, drink 4 to 6 glasses of clear liquids.
- Apply zinc oxide ointment or Desitin® to the skin around your anus after every bowel movement. This helps prevent irritation.
At 7:00 pm on the day before your surgery, take your antibiotics as instructed.
At 10:00 pm on the day before your surgery, take your antibiotics as instructed.
You can keep drinking clear liquids until midnight, but you don’t have to.
Note the Time of Your Surgery
A staff member from the Admitting Office will call you after 2:00 pm the day before your surgery. If your surgery is scheduled for a Monday, they will call you on the Friday before. If you don’t get a call by 7:00 pm, please call 212-639-5014.
The staff member will tell you what time to arrive at the hospital for your surgery. They will also remind you where to go.
Shower With Hibiclens®Hibiclens is a skin cleanser that kills germs for 24 hours after you use it (see figure). Showering with Hibiclens before your surgery will help lower your risk of infection after surgery. Your nurse will give you a bottle of Hibiclens to use before your surgery.
The night before your surgery, shower using Hibiclens.
- Use your normal shampoo to wash your hair. Rinse your head well.
- Use your normal soap to wash your face and genital area. Rinse your body well with warm water.
- Open the Hibiclens bottle. Pour some solution into your hand.
- Move away from the shower stream to avoid rinsing off the Hibiclens too soon.
- Rub the Hibiclens gently over your body from your neck to just above your genital area. Don’t put the Hibiclens on your face or genital area.
- Move back into the shower stream to rinse off the Hibiclens. Use warm water.
- Dry yourself off with a clean towel after your shower.
- Don’t put on any lotion, cream, deodorant, makeup, powder, perfume, or cologne after your shower.
Shower With Hibiclens
Shower using Hibiclens just before you leave for the hospital. Use the Hibiclens the same way you did the night before.
Don’t put on any lotion, cream, deodorant, makeup, powder, perfume, or cologne after your shower.
Things to Remember
- Wear something comfortable and loose-fitting.
- If you wear contact lenses, wear your glasses instead. Wearing contact lenses during surgery can damage your eyes.
- Don’t wear any metal objects. Remove all jewelry, including body piercings. The equipment used during your surgery can cause burns if it touches metal.
- Don’t put on any lotion, cream, deodorant, makeup, powder, perfume, or cologne.
- Leave valuable items (such as credit cards, jewelry, and your checkbook) at home.
- If you’re menstruating (have your monthly period), use a sanitary pad, not a tampon. You’ll get disposable underwear, as well as a pad if needed.
- Before you’re taken into the operating room, you will need to remove your hearing aids, dentures, prosthetic device(s), wig, and religious articles.
What to Bring
- A pair of loose-fitting pants (such as sweat pants).
- Brief-style underwear that’s 1 to 2 sizes larger than you normally wear.
- Sneakers that lace up. You may have some swelling in your feet. Lace-up sneakers can fit over this swelling.
- Your breathing machine for sleep apnea (such as your CPAP machine), if you have one.
- Your portable music player, if you choose. However, someone will need to hold it for you when you go into surgery.
- Your Health Care Proxy form and other advance directives, if you have completed them.
- Your cell phone and charger.
- Only the money you may want for small purchases (such as a newspaper).
- A case for your personal items (such as eyeglasses, hearing aid(s), dentures, prosthetic device(s), wig, and religious articles), if you have one.
- This guide. Your healthcare team will use this guide to teach you how to care for yourself after your surgery.
Once You’re in the Hospital
When you get to the hospital, take the B elevator to the 6th floor and check in at the desk in the PSC waiting room.
You will be asked to say and spell your name and birth date many times. This is for your safety. People with the same or a similar name may be having surgery on the same day.
During Your Surgery
After you’re fully asleep, a breathing tube will be placed through your mouth and into your windpipe to help you breathe. You will also have a urinary (Foley®) catheter placed to drain urine (pee) from your bladder.
Once your surgery is finished, your incisions will be closed with stitches (sutures), staples, Dermabond® (surgical glue), or Steri-Strips™ (surgical tape). You may also have a bandage over your incisions.
Your breathing tube is usually taken out while you’re still in the operating room.Back to top
After Your Surgery
When you wake up after your surgery, you will be in the Post Anesthesia Care Unit (PACU).
A nurse will be monitoring your body temperature, pulse, blood pressure, and oxygen levels. You may be getting oxygen through a thin tube that rests below your nose or a mask that covers your nose and mouth. You will also have compression boots on your lower legs.
You will get medication to control your pain and keep you comfortable. There are different ways that pain medication can be given:
- Epidural catheter: Some people get pain medication through an epidural catheter (thin, flexible tube in their spine).
- Nerve block: Some people get a nerve block before or during surgery. With a nerve block, your doctor injects medication into some of your nerves to reduce pain after surgery.
- IV medications: Some people get pain medication straight into a vein through their IV line.
You will have 1 or more of these after your surgery. They’re all effective methods to control your pain. Your doctor will talk with you before choosing the best one(s) for you.
Tubes and Drains
You will have 1 or more of the tubes and drains below. Your doctor or nurse will talk with you about what to expect.
- You will have a Foley catheter in your urethra going into your bladder. This tube drains urine from your bladder so your care team can keep track of how much urine you’re making.
- You will have 1 or 2 drains in your lower abdomen. These drain extra fluid from the area. These drains are usually removed after a few days. If you will go home with a drain, your nurse will show you how to care for it.
Moving to Your Hospital Room
You will stay in the PACU until you’re awake and your pain is under control. Most people are moved to their hospital room after a few hours in the PACU, but some people stay in the PACU overnight for observation. After your stay in the PACU, you will be taken to your hospital room.
The length of time you’re in the hospital after your surgery depends on your recovery and the exact surgery you had. Most people stay in the hospital for 4 to 5 days. Your healthcare team will tell you what to expect.
When you’re taken to your hospital room, you will meet one of the nurses who will care for you while you’re in the hospital. While you’re in the hospital, your nurses will teach you how to care for yourself while you’re recovering from your surgery. You can help yourself recover more quickly by doing the following things:
- Read your recovery pathway. Your nurse will give you a pathway with goals for your recovery, if you don’t already have one. It will help you know what to do and expect on each day during your recovery.
- Start moving around as soon as you can. The sooner you’re able to get out of bed and walk, the quicker you will be able to get back to your normal activities.
Read the resource Call! Don't Fall! to learn about what you can do to stay safe and keep from falling while you’re in the hospital.
Managing Your Pain
You will have some pain after your surgery. At first, you will get your pain medication through an epidural catheter, nerve block, or IV line. Once you’re able to swallow liquids, you will get oral pain medication (pain medication that you swallow).
Your doctor and nurse will ask you about your pain often and give you medication as needed. If your pain isn’t relieved, tell your doctor or nurse. It’s important to control your pain so you can cough, breathe deeply, use your incentive spirometer, and move around. Controlling your pain will help you recover better.
Many people find their pain is controlled with over-the-counter medications alone. If you need stronger pain medication in the hospital, you will be given a prescription before you leave. Talk with your doctor or nurse about possible side effects and how to taper (slowly stop taking) your medication.
Moving Around and Walking
Moving around and walking will help lower your risk for blood clots and pneumonia. It will also help stimulate your bowels so you start passing gas and having bowel movements (pooping) again.
Read your recovery pathway to learn about your specific moving and walking goals. Your nurse, physical therapist, or occupational therapist will help you move around, if needed.
Exercising Your Lungs
It’s important to exercise your lungs so they expand fully. This helps prevent pneumonia.
- Your nurse will give you an incentive spirometer. Use it 10 times every hour you’re awake. For more information, read How to Use Your Incentive Spirometer.
- Do coughing and deep breathing exercises. A member of your care team will teach you how to do these exercises.
Eating and Drinking
For the first few days after your surgery, you won’t be able to eat solid foods. You will follow a clear liquid diet. After that, you will slowly go back to eating solid foods. Read your pathway and talk with your care team for more information.
Your doctor will give you dietary guidelines to follow after your surgery. A clinical dietitian nutritionist will visit you in your hospital room to go over these guidelines with you before you leave the hospital.
If you have questions about your diet, ask to see a clinical dietitian nutritionist.
Caring for Your Incisions
Your care team will check your incisions daily. Keep your incisions clean and dry. You may notice small amounts of light pink fluid leaking from your perineal area. This is normal. You can wear Depends® or another type of shield to protect your clothing from stains.
For several weeks after your surgery, there will be restrictions on how you sit, lie down, and carry out some of your daily activities. You won’t be able to sit for long periods of time and you will need to sleep on your side. Your doctor or nurse will go over these restrictions with you.
Caring for Your Colostomy Stoma
Your nurses, WOCN, or both will check your stoma every day. You will have a pouch in place to collect any stool that exits from your stoma.
Your WOC nurse will visit you in your hospital room to teach you how to care for your colostomy. For more information, read Caring for Your Ileostomy or Colostomy.
Leaving the Hospital
By the time you’re ready to leave the hospital, your incision will have started to heal. Before you leave the hospital, look at your incisions with your nurse and caregiver. Knowing what your incisions look like will help you notice any changes later.
On the day of your discharge, you should plan to leave the hospital between 8:00 am and 10:00 am. Before you leave, a member of your care team will write your discharge order and prescriptions. You will also get written discharge instructions. Your nurse will review these instructions with you before you leave.
If you have sutures or staples in your abdominal incision(s), they’re usually removed the morning you leave the hospital. This is done in your hospital bed and isn’t painful. If you go home with staples or sutures in place, you will need to come back to the clinic to have them removed.
If your ride isn’t at the hospital when you’re ready to be discharged, you may be able to wait in the Patient Transition Lounge. A member of your healthcare team will give you more information.
Read the resource What You Can Do to Avoid Falling to learn about what you can do to stay safe and keep from falling at home and during your appointments at MSK.
Managing Your Pain
People have pain or discomfort for different lengths of time. You may still have some pain when you go home and will probably be taking pain medication. Some people have soreness, tightness, or muscle aches around their incisions as they recover. This doesn’t mean that something is wrong. But, if it doesn’t get better, contact your doctor’s office.
Follow the guidelines below to help manage your pain.
- Take your medications as directed and as needed.
- Call your doctor if the medication prescribed for you doesn’t ease your pain.
- Don’t drive or drink alcohol while you’re taking prescription pain medication.
- As your incisions heal, you will have less pain and need less pain medication. An over-the-counter pain reliever such as acetaminophen (Tylenol®) or ibuprofen (Advil®) will ease aches and discomfort.
- Follow your doctor or nurse’s instructions for stopping your prescription pain medication.
- Don’t take more acetaminophen than the amount directed on the bottle or as instructed by your doctor or nurse. Taking too much acetaminophen can harm your liver.
- Pain medication should help you resume your normal activities. Take enough medication to make sure you can gradually increase your activities. However, it’s normal for your pain to increase a little as you start to be more active.
- Keep track of when you take your pain medication. It works best 30 to 45 minutes after taking it. Taking it when your pain first begins is better than waiting for the pain to get worse.
Pain medication may cause constipation (having fewer bowel movements than what’s normal for you).
Talk with your nurse about how to manage constipation. You can also follow the guidelines below.
- Go to the bathroom at the same time every day. Your body will get used to going at that time. But, if you feel like you need to go, don’t put it off.
- Try to use the bathroom 5 to 15 minutes after meals. After breakfast is a good time to move your bowels. The reflexes in your colon are strongest at this time.
- Exercise, if you can. Walking is an excellent form of exercise.
- Drink 8 to 10 (8-ounce) glasses (2 liters) of liquids daily, if you can. Drink water and other liquids, including juices (such as prune juice) and soups.
- Both over-the-counter and prescription medications are available to treat constipation. Talk with your nurse about which medication is best for you.
If you have questions about constipation, contact your doctor’s office.
Caring for Your Incisions
It’s normal for the skin below your incisions to feel numb. This happens because some of your nerves were cut during your surgery, even if you had a nerve-sparing procedure. The numbness will go away over time.
Check your incisions every day for any signs of infection until your doctor tells you they’re healed. Call your doctor if you develop any of the following signs of a wound infection:
- Increased pain
- Warmth at the incision site
- Foul-smelling or pus-like drainage from your incision
- A fever of 100.5 °F (38 °C) or higher
To keep from getting an infection, don’t let anyone touch your incisions. Clean your hands with soap and water or an alcohol-based hand sanitizer before you touch your incisions.
If you go home with staples or sutures in your incisions, your doctor will take them out during one of your appointments after surgery. It’s okay to get them wet. If you go home with Steri-Strips or Dermabond on your incisions, they will loosen and peel off by themselves. If they haven’t fallen off after about 14 days, you can take them off.
The sutures in your perineal incision will either dissolve over time or will need to be removed. Your surgeon will tell you if you need to have your sutures removed.
The time it takes the perineal area to heal is different from person to person, but it usually takes about 3 months. Your discomfort will decrease over time.
Shower every day. Taking a warm shower is relaxing and can help ease muscle aches. You will also clean your incision when you shower.
Take your bandages off before you shower. When you shower, gently wash your incisions with a fragrance-free, liquid soap. Don’t scrub your incisions or use a washcloth on them. This could irritate them and keep them from healing.
When you’re finished with your shower, gently pat your incisions with a clean towel. Let them air dry completely before getting dressed. If there’s no drainage, leave your incisions uncovered.
Don’t take tub baths or go swimming until your doctor says it’s okay.
Eating and Drinking
Your doctor will give you dietary guidelines to follow after your surgery. If you need to reach a clinical dietitian nutritionist after you go home, call 212-639-7312.
Physical Activity and Exercise
When you leave the hospital, your incisions may look like they’re healed on the outside, but they won’t be healed on the inside. For the first 6 weeks after your surgery:
- Don’t lift, push, or pull anything heavier than 10 pounds (about 4.5 kilograms).
- Don’t do any strenuous activities (such as jogging and tennis).
- Don’t play any contact sports (such as football).
Walking is a good way to increase your endurance. You can walk outside or indoors at your local mall or shopping center. You can also climb stairs, but try to limit how often you do this for the first week you’re home. Don’t go out by yourself until you’re sure of what you can do.
It’s normal to have less energy than usual after your surgery. Recovery time is different for each person. Increase your activities each day as much as you can. Always balance activity periods with rest periods. But, if you can’t sleep at night, it may be a sign that you’re resting too much during the day.
Ask your doctor when you can drive. Don’t drive while you’re taking pain medication that may make you drowsy.
You can ride in a car as a passenger at any time after you leave the hospital.
Your doctor will tell you when you can start having sexual activity.
The nerves that control sexual function are in your pelvis. You may worry that they will be damaged after your surgery. Surgeons at MSK have special training to lower this risk. Only a small number of people have changes in sexual function after their surgery. If you have any concerns about sexual function, talk with your surgeon.
Changes in Urinary Function
The nerves that control urination are also in your pelvis. There’s a small chance that you may have changes in urinary function after your surgery. Your surgeon will do everything they can to protect these nerves. But, a small number of people lose urinary control for a short time after surgery.
If this happens to you, you may need to use a catheter for a longer amount of time after your surgery. Permanent loss of urinary control is uncommon. Your surgeon will discuss this risk with you. You can also speak to your doctor, nurse, and social worker.
Going Back to Work
Talk with your doctor or nurse about your job and when it may be safe for you to start working again. If your job involves lots of movement or heavy lifting, you may need to stay out a little longer than if you sit at a desk.
Getting Your Test Results
After your surgery, the tumor and the tissue around it will be sent to a pathologist. Your test results will be ready about 5 business days after your surgery. Your surgeon will talk with you about the results of the tests and recommend whether you need any additional treatments.
Your first appointment after your surgery will be 1 to 3 weeks after you leave the hospital. Call your surgeon’s office after you’re discharged from the hospital to schedule it.
It’s important that you go to all of your follow-up appointments after your surgery. You can call your doctor or nurse if you have any questions in between these appointments.
- A fever of 100.5 °F (38 °C) or higher
- Pain in your abdomen, nausea, and vomiting
- Any of the following signs of infection in your incision:
- Increased pain
- Warmth at the incision site
- Foul-smelling or pus-like drainage
- Difficulty urinating (peeing)
- Pain at your incision that isn’t eased by pain medication
- Any questions or concerns
Monday through Friday from 9:00 am to 5:00 pm, contact your doctor’s office.
After 5:00 pm, during the weekend, and on holidays, call 212-639-2000 and ask to speak to the doctor on call for your doctor.Back to top
The Ostomy Association
Wound Ostomy Continence Organization
Go to this website to find a CWOCN in your area. The website also has information on resources, suppliers of ostomy products, and support groups.
General SupportBack to top
- Advance Care Planning
- Call! Don't Fall!
- Caring for Your Ileostomy or Colostomy
- Common Medications Containing Aspirin and Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
- Herbal Remedies and Cancer Treatment
- How to Be a Health Care Agent
- How to Enroll in the Patient Portal: MyMSK
- How to Use Your Incentive Spirometer
- Information for Family and Friends for the Day of Surgery
- Liquid Intake and Ostomy Output Log
- What You Can Do to Avoid Falling