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What Happens During a Proctectomy?

This is the most common surgery used to treat rectal cancer. It is surgery that removes part or all of your rectum. Your rectum lies deeper within your pelvis and is close to your spine. This makes it difficult to get to. It's also close to other important structures like major blood vessels, your bladder, and your prostate if you're a man, and your vagina if you're a woman. Working so closely to these structures increases the risk of injuring them. If you are obese or have a narrow pelvis, surgery becomes even more difficult.

Rectal surgery also comes with potentially life-altering side effects. In many cases, a person doesn't resume normal bowel function after surgery. Sometimes your anal sphincter muscles, which are the muscles that hold your stool in until you're ready to go to the bathroom, have to be removed. You may then need a small hole in your abdomen for stool to pass through and collect in a bag. This is called a colostomy.

There are several ways a surgeon can do a proctectomy for rectal cancer. They vary based on where the tumor is and where the surgeon makes the incision.

  • Local transanal resection or transanal excision (also called TAE). For this type of surgery, your surgeon cuts through all the layers of your rectum and removes the tumor. The surgeon operates through the anus and removes the tumor and only part of the rectum wall. That leaves your lymph nodes behind. TAE is a sphincter-saving surgery, so it does not require a colostomy. However, if your lymph nodes contain microscopic cancer cells, they can be a source for recurrent cancer. For this reason, you are only a candidate for this surgery if your tumor is small and not very aggressive.

  • Anterior resection (also called AR). This surgery is used for tumors high up in the rectum. The surgeon removes the tumor through an incision in your lower abdomen. The surgeon also removes your upper rectum and lower part of the colon. Then he or she reconnects the ends of your colon.

  • Low anterior resection (also called LAR). This surgery is used for tumors in the mid and lower rectum. The surgeon reaches your bowel through an incision in your lower abdomen. The doctor takes out most of your rectum and the muscles around it, down to the muscles of your anal sphincter. Your surgeon then joins your colon to the lowest portion of the rectum. Because a permanent colostomy is not required, this operation is considered to be a sphincter-saving procedure. The anal sphincter is a circular muscle that allows you to hold stools inside until you are ready to have a bowel movement. Keeping it allows you to maintain normal bowel function after surgery. This is the typical surgery for low tumors. It has a low rate of tumor recurrence inside the pelvis.

  • Abdominoperineal resection (also called APR). APR used to be the standard surgery for tumors of the lower rectum. Now, it is usually limited to large tumors that lie very low down in the rectum and affect the muscles of the anal sphincter. It requires 2 incisions. The surgeon makes one through your abdomen. The second goes around your anus in the perineum. This is the area surrounding your anus and genitals. During an APR, the surgeon removes your anus, rectum, and the surrounding muscles of the anal canal. Because the muscles of your anal sphincter are removed, you do not regain normal bowel function. That means you will need a colostomy. This creates an opening on your abdomen where waste can leave your body and collect in a bag.

  • Pelvic exenteration. This is a major surgery used for advanced cancer that has grown into nearby organs. The surgeon removes all of your rectum and other organs, such as your bladder, prostate, or uterus. After the surgery, you may need both a colostomy and a urostomy. A urostomy is an opening in your abdomen for your urine to pass through and collect in a bag. 

  • In cases where rectal cancer has spread but has only reached small parts of the liver or lungs, other operations may sometimes be done along with rectal surgery.  

  • Metastasectomy. If a limited amount of cancer has spread to other organs such as the liver or lungs, surgery to remove these tumors may help you live longer or even cure the cancer. This is only an option if the main rectal tumor can also be removed completely. 

  • Other ways to destroy metastases. In some cases, small amounts of cancer that has spread can be destroyed through nonsurgical techniques. For example, cryosurgery uses a thin metal probe to freeze--and destroy--tumor cells that have spread to your liver. Radiofrequency ablation (also called RFA) is a procedure that uses a long, thin metal probe to heat and kill tumors that have spread from the rectum to other organs, such as your liver. If you're not a good candidate for a liver resection, cryosurgery, or RFA, or other nonsurgical techniques may provide an alternative.