What kinds of surgery are there?
Some early-stage colorectal cancers can be removed during a colonoscopy. Other tumors require more extensive procedures — which come with additional prep work and recovery time.
How surgery is used in a treatment plan and the timing of surgery depends on the stage and location of the tumor(s). Other factors include your health, risk of disease growth, goal and type of surgery, chance of recurrence and risks to the organs involved. Similarly, your eligibility for surgery depends on the moment in time and can change as your disease, health and circumstances change.
It’s important to talk with a surgeon to get an opinion about your eligibility for surgery. You may want to talk with multiple surgeons, as opinions can vary.
Here are some of the procedures that colorectal cancer patients commonly have:
Primary tumor procedures
- Polypectomy
- Local excision
- Colectomy/Resection
- Exploratory laparoscopy
- Fecal diversion (colostomy or ileostomy placement)
- Ostomy reversal
Sound like a lot of different options? We’ll walk you through what all these words mean. And warning — there are some images and depictions of surgery ahead.
Primary tumor procedures
Polypectomy
Polyps are growths that stick out from the lining of the colon or rectum. These growths may contain cancer, or may develop into a cancerous tumor if left unchecked. Polyps are usually found during a colonoscopy, and this minimally-invasive procedure is done to remove them.
Local excision
This procedure is done on very early stage tumors. The doctor uses a colonoscope inserted into the anus to remove the tumor, along with some surrounding healthy tissue. This procedure is minimally invasive and usually done as an outpatient procedure.
Colectomy/Resection
Through a colectomy, part or all of the colon is removed. This is also commonly referred to as a resection. This is a major surgery that may require significant preparation and recovery, depending on the surgical methods used and type of colectomy. This surgery may result in a temporary ostomy. Here are some of the types of colectomies available.
Lower anterior resection (LAR)
In this surgery, the upper part of the rectum is removed, along with local lymph nodes. Depending on various factors, a temporary ileostomy may be required.
Abdominoperineal resection (APR)
This procedure is referred to humorously by COLONTOWNies as the “Barbie/Ken butt surgery” because the sigmoid colon, rectum, and anus are completely removed. The area where the anus used to be is stitched up. This surgery is done when patients have tumors that invaded all those areas. In some cases where patients have had prior radiation for a rectal tumor, the surgeon may need to transplant a section of the abdominal or thigh muscle to strengthen the area and help the incision heal properly. After this procedure, patients will have a permanent colostomy.
Partial colectomy
This is also referred to as a hemicolectomy or segmental resection. In this procedure, a surgeon removes part of the colon, its blood supply, the peritoneal covering and nearby lymph nodes in one block. The remaining parts are joined together after in a procedure called anastomosis. If your tumor is not too large, and in an area that can be easily reconstructed, you may have this procedure. The image below shows an example of one type of partial colectomy.
Right colectomy
This procedure is done when a patient has a right-sided tumor that requires removal of the entire right side of the colon. All lymph nodes in the area are removed.
Proctosigmoidectomy
Patients who have this surgery usually have tumors in the sigmoid colon and rectum. During this operation, the diseased part of the sigmoid colon and rectum are removed, along with local lymph nodes. The surgeon can usually connect the sigmoid colon to the anus, so an ostomy is sometimes not required.
Proctectomy
This surgery is usually done for stage II and III rectal cancer patients who have tumors in the middle or lower third of the rectum. The procedure involves the removal of the entire rectum, including all lymph nodes near the rectum. The surgeon can usually connect the colon and anus, so patients may not need an ostomy. Sometimes a surgeon may put a colonic j-pouch in to prevent a permanent ostomy. In this case, the surgeon doubles back a small section of the colon to serve as a pouch to hold stool in place of the rectum. If this happens, patients may require a temporary ileostomy while the surgical site heals.
Pelvic exenteration
This operation is done when a patient has a rectal tumor that has grown into nearby organs. In that case, the entire rectum, along with any diseased organs, such as the bladder, prostate, or vagina are removed. This surgery requires a permanent colostomy, as well as a urostomy or nephrostomy if the bladder is removed.
Total colectomy
In this procedure, the entire colon is removed. After a total colectomy, patients will have a permanent colostomy. This is usually a prophylactic surgery done for people who have an inherited predisposition to colorectal cancer.
Total proctocolectomy
This is an extensive bowel operation. It involves the removal of the entire rectum and colon. After this procedure, patients have a permanent colostomy. This is usually a prophylactic surgery done for people who have an inherited predisposition to colorectal cancer and are not applicable to everyone.
Confused about all the different types of resections?
Here’s an image that should make things clearer:
Exploratory laparoscopy
An exploratory laparoscopy or diagnostic laparoscopy is a minimally invasive procedure done to diagnose disease that can’t be seen well on scans. This procedure can be done for other reasons too, such as to take a better look at possible peritoneal metastases. In CRC, this is sometimes used for patients with peritoneal mets to determine whether a patient is a candidate for cytoreductive surgery or HIPEC. In this procedure, the surgeon makes several small incisions in the abdomen, and inserts a laparoscope (a small camera) to take images. After the procedure, the laparoscope is removed and the incisions are stitched up.
Fecal diversion (colostomy or ileostomy placement)
Usually, poop travels through the colon, rectum and finally, anus. When the path between stomach and anus is disrupted by surgery, poop needs to be diverted elsewhere. In a fecal diversion surgery, surgeons create a stoma — an opening of the bowel through the skin. In a colostomy, the end of the colon is attached to the skin. In an ileostomy, the small intestine is attached to the skin. Ostomies may be temporary or permanent, depending on the type of surgery. This surgery can be done at the same time as another resection surgery, or is done when there is an issue like a blockage. For more information about ostomies, check out our ostomy section.
Ostomy reversal
As mentioned above, some ostomies are temporary and are meant to give the surgical site time to heal. If you have a temporary ostomy, you will likely have it reversed at some point. In this procedure, the surgeon takes the piece of colon that formed your stoma and reconnects it to the rest of your intestines. For more information on what happens after ostomy reversal, and how to help get your bowels working again, see our section on ostomy reversal.
Want to learn more about surgical options?
Watch this webinar by FightCRC.
Metastases procedures
Lung resection
If your cancer has spread to the lungs, you might have a lung resection. In this procedure, part or all of the lung is removed. This procedure can be done either through traditional open surgery, or through more minimally invasive procedures, such as video-assisted thoracoscopic surgery (VATS). In this procedure, the surgeon makes several small cuts, then uses a special camera called a thoracoscope to help locate and remove tumors. This procedure is usually done one lung at a time
For more information on lung resection, see this article from the Cleveland Clinic.
HIPEC
Hyperthermic intraperitoneal chemotherapy (HIPEC) is a two-part treatment used to treat cancer that has spread to the peritoneum (the lining that surrounds the abdomen). The first step is called tumor debulking, or cytoreductive surgery (CRS). In this procedure, the surgeon cuts into the peritoneum and removes any tumors that they can find. Next, heated chemotherapy drugs are delivered directly into the abdomen to treat any microscopic cancer cells that remain. The combination of heat and chemotherapy can eliminate more cancer cells than can be found by the naked eye. This is a very specialized and extensive surgery and often takes more than 10 hours to complete.
HAI pump placement
A hepatic artery infusion (HAI) pump is used to treat cancer that has spread to the liver. This is usually done in patients with limited liver disease. In this procedure, a device the size of a hockey puck is implanted in the skin between the ribs and pelvis, and is connected to the liver by a small catheter. It delivers targeted, concentrated chemotherapy to the liver. HAI pumps are often placed during surgery to remove liver tumors. Research has shown that patients who have a HAI pump placed during liver resection may have a lower chance of liver reoccurrence than those who did not have a HAI pump placed. However, the HAI pump is not available at every cancer center, so you may have to travel to receive this treatment.
Watch this DocTalk with Dr. Gholami from UC Davis for more information on the HAI pump:
Liver resection
Some patients with liver metastases will qualify for surgery to remove their liver tumors. Sometimes the surgeon will remove only the sections of liver that contain tumors, while other times, the entire right or left lobe of the liver is removed. The liver has the capability of regenerating after surgery, so some patients may have up to 70% of the liver safely removed. If tumors are located on both lobes of the liver, it’s sometimes possible to remove them in two separate surgeries.
Liver surgery may be part of a larger treatment plan. In addition to surgery, patients may need chemotherapy, radiation therapy, or other treatments in combination with liver resection. When deciding whether or not liver resection is a good option, surgeons will consider the location and size of the tumors, as well as any other tumors the patient has.
DocTalk: Dr. Hernandez-Alejandro gives an overview of surgical options for liver mets:
Want to learn more about liver resection?
Check out this guide by the UCSF Helen Diller Family Comprehensive Cancer Center: Understanding Liver Resection
Liver transplant
Liver transplant surgery is currently being used to treat CRC patients with liver-limited disease. A liver transplant usually requires a living liver donor and the patient has to meet very specific criteria in terms of their diagnosis, overall health and performance status.
Meet four liver transplant patients and hear about their experiences:
Why liver transplant for mCRC is taking off: Dr. Hernandez-Alejandro
Local treatments
Ablation
Ablation is a minimally-invasive technique that is commonly used to treat small liver and lung mets. This procedure is done by inserting a needle or probe into the tumor. The surgeon uses scanning technology to guide the needle into the correct position. Depending on the type of ablation, the needle delivers a dose of either high heat or extreme cold to kill the cancer cells.
Ablation is most successful with mets that are smaller than 3cm or 1 inch, and can only be used to treat a limited number of tumors — although doctors don’t always agree on what number that is. Ablation damages a small number of healthy cells surrounding the tumors, so it may not be possible if the tumor is near a major blood vessel, bile duct, or other sensitive area in the body.
Ablation is a procedure with few side effects, although some patients may experience mild pain or discomfort, temporarily reduced lung or liver function, elevated temperature, and in rare cases infection. If you experience any of these side effects, communicate with your team so they can help you manage them.
There are several types of ablation that may be used:
Radiofrequency ablation (RFA)
This is the most commonly used type of ablation. In radiofrequency ablation, a needle or probe is inserted through the skin into the tumor and high-energy radio waves heat up the tumor and kill cancer cells.
Microwave ablation (MWA)
In microwave ablation, a needle or probe is inserted into the tumor and electromagnetic waves are used to heat up the tumor and kill the cancer cells.
Cryoablation (Cryotherapy)
In cryoablation, a metal probe is inserted into the tumor and cold gasses are injected into the tumor. This causes the tumor to freeze, killing the cancer cells.
Want to learn more about surgical options?
Watch this webinar by FightCRC.
Want to learn more about surgery?
Join one of our COLONTOWN Facebook groups:
- COLONTOWN Downtown Come visit COLONTOWN’s main street for general discussions about surgery
- Corner Cupboard for discussions on side effect management
- Palliative Pathways for advice on how your palliative care team can help you cope with side effects
- Rectalburgh for patients with rectal cancer
- Liver Lover’s Lane for info on treatment for liver mets
- Lungston for info on treatment for lung mets
- Peri Place & HIPEC Heights for info on treatment for peritoneal mets
- Transplantation Station for info on liver transplant surgery
- HAI Pump People for info on the HAI Pump for liver mets
Want to join? Fill out the registration form here.
COLONTOWN University has so much more to offer, from DocTalk videos with CRC experts to easy-to-understand biomarker test breakdowns. We’re here for you! See our list of Learning Centers here.