Laparoscopic surgery of the colon and rectum

What is laparoscopic surgery?

In traditional (open) surgery a long cut is made on the abdomen; according to ASCRS usually 6 to 12 inches, about 15 to 30 centimeters. In minimally invasive or “laparoscopic” surgery, a few small cuts are made instead. A thin camera and special instruments go in through these cuts and the surgeon watches the picture on a screen. The aim of the operation is the same as in open surgery; the difference is in how the bowel is reached.

This page is about the method itself and the conditions that may lead to it. Who needs it is only known after an examination and tests. Most problems of the large bowel never reach an operation.

Which conditions sometimes lead to bowel surgery?

Diverticulitis

Diverticula are small pouches that push out from the wall of the large bowel. Having them (diverticulosis) usually causes no symptoms. When one of the pouches becomes inflamed or infected, it is diverticulitis: constant pain, often in the lower left abdomen, sometimes with fever.

• Most uncomplicated attacks are treated with antibiotics (not always needed) and a temporary liquid or low-fiber diet, usually without admission.
• Surgery is considered in these situations: a hole in the bowel with infection in the abdomen (usually an emergency), an abscess that has not cleared with medicine and drainage, a narrowing or blockage, a fistula (an abnormal connection, for example to the bladder), or no progress with medical treatment.
• After an uncomplicated attack, preventive removal of the bowel is no longer automatically advised. The decision depends on the number and severity of attacks, persistent symptoms, age and general health.
• A colonoscopy is usually advised a few weeks after recovery so that another condition, including cancer, is not missed.

Large polyps

A polyp is a small bump on the lining of the bowel. Most polyps do not become cancer, but because there is no test to predict this, removing them is advised. Almost all polyps are removed during the colonoscopy itself, and a large polyp may need more than one session. ASCRS also names removal from inside the bowel (EMR and ESD) and removal through the anus for lesions in the rectum (TAMIS and TEM).

ASCRS says an operation to remove a polyp completely is rare, and a rectal lesion suspected of being cancerous may be treated by local removal through the anus. When exactly an abdominal operation is needed in your case is explained by the surgeon after seeing the colonoscopy and pathology reports.

Inflammatory bowel disease (ulcerative colitis and Crohn’s disease)

In both diseases the first treatment is medicine, usually with a gastroenterologist. Surgery is considered when medicine does not control the disease or a complication has occurred (for example a hole, heavy bleeding, blockage or fistula) or a pre-cancerous lesion has been seen on colonoscopy.

• In ulcerative colitis, because the disease involves only the colon and rectum, removing them can remove the bowel disease (although the operation itself has stages and complications). Sometimes this is done in several stages and a temporary ileostomy is needed between them.
• Crohn’s disease has no definite cure; surgery treats the complication and the disease may return later. The surgeon tries to keep as much bowel length as possible.

Colon and rectal cancer

Bowel cancer has its own page. Here, just know that for colon cancer, ASCRS says several large studies have shown the same cancer outcome for open and minimally invasive surgery, provided the surgeon is trained and the principles of cancer surgery are followed.

Other conditions

Minimally invasive surgery may also be used for rectal prolapse.

Types of minimally invasive approach

ASCRS explains the names like this. Which approach suits or is available to you is something the surgeon tells you.

• Laparoscopic: usually 3 to 5 cuts of about half an inch (about 1 to 1.5 centimeters). The abdomen is filled with carbon dioxide gas to make room. The removed section usually comes out through one cut of about 2 to 4 inches.
• Hand-assisted (HALS): a device is placed in a 2 to 4 inch cut so the surgeon can put a hand inside.
• Single-incision: the camera and instruments go in through one cut of about 2 inches. The scar is less visible, but the work is harder for the surgeon.
• Robotic: the surgeon sits at a console with a 3D display and the machine transfers their hand movements to the instruments. It is considered suitable for narrow spaces such as the pelvis.
• Laser: ASCRS states plainly that lasers are not used in minimally invasive surgery and the phrase “laparoscopy with laser” is an outdated term.

How is the operation done?

All of these operations are done under general anesthesia. The general steps:

1. A few small cuts are made on the abdomen and the camera and instruments are put in.
2. The diseased section of bowel (and nearby lymph nodes if it is cancer) is separated and removed.
3. If possible and safe, the two healthy ends of the bowel are joined (anastomosis).
4. If joining is not safe, or the bowel needs rest, a temporary or permanent bag (stoma) is made.
5. The cuts are closed.

For preparation before the operation, see the guide “Preparing for surgery”.

If the operation is converted to open

Sometimes during the operation, because of adhesions, bleeding, the amount of disease or another problem, continuing laparoscopically is not safe. The surgeon makes the cut larger and finishes the operation open. ASCRS calls this “surgical judgment, not a complication”. Ask the surgeon before the operation how likely it is in your case.

After the operation

• ASCRS says there is usually less pain, a shorter stay, less need for strong pain medicine and an earlier return to normal activities, and the scars are less visible. The same source says the long-term outcome of the two methods is similar.
• Many hospitals have an “enhanced recovery” (ERAS) program: early walking and eating, combined pain relief and fluid control. See the guides “Care after surgery” and “Eating after surgery”.
• The sources do not give fixed numbers for the length of the hospital stay or the return to work. Full recovery time varies a lot between patients and depends on the operation, the disease, age and general health.
• If a stoma has been made, a specialist stoma nurse teaches you how to care for it.

Risks

A bowel operation is a major operation and is not risk-free. ASCRS says complications of laparoscopic surgery are similar to those of open surgery:

• Bleeding and infection of the wound or inside the abdomen
• Opening or leaking of the join in the bowel; one source gives the leak risk after removing part of the bowel for diverticulitis as about 5% in patients in good general condition and 6 to 19% in patients who are unwell. Smoking, steroids and diabetes make healing worse
• Bowel blockage (obstruction) after the operation
• Clots in the leg veins and, rarely, travel of a clot to the lung
• Pneumonia, urinary infection, heart problems with a major operation under general anesthesia
• Injury to nearby organs such as the ureter (for example in a sigmoid operation)
• Overall, according to ASCRS, in colon surgery for cancer about one in five patients has some kind of complication, from mild ones such as a wound infection to one that needs another operation

Your personal risk depends on age, other illnesses, how urgent the operation is and the type of disease, and should be discussed with the surgeon and anesthetist.

When to call

After discharge, call the surgeon or treatment center if:

• You have fever, chills or abdominal pain that is getting worse
• You see redness, warmth, swelling or discharge from the cuts
• You have persistent nausea and vomiting or cannot drink fluids
• Your abdomen is swollen and you are not passing gas or stool
• You cannot pass urine
• A calf becomes painful and swollen

Chest pain, sudden shortness of breath, heavy bleeding, or weakness and confusion is an emergency: call 115 (Iran’s emergency number). The full list is in the guide “When should I call urgently?”.

Every patient’s treatment plan is different; ask your doctor about your own situation.