Surgery of colon and rectum is done for various reasons including cancer, diverticulitis, inflammatory

bowel disease, volvulus and fistulae.

Anatomy and Physiology

The large bowel absorbs 90% of the water content of the digested food it receives from the
small intestine.

It also propels the residue towards the rectum, where it is stored and expelled with a bowel
movement

The large bowel is composed of:

1. Colon. The colon averages 150 cms. (60 inches) in length. The colon is divided into
four segments: the ascending colon, transverse colon, descending colon and sigmoid
colon. There are two bends (flexures) in the colon. The hepatic flexure is where the
ascending colon joins the transverse colon. The splenic flexure is where the
transverse colon merges into the descending colon. (Figure 1)
2. Cecum. This is the first portion of the large bowel and is joined to the small bowel.
The appendix lies at the lowest portion of the cecum. (see Appendectomy)
3. The ascending colon is about eight inches in length, extends upwards from the
cecum to the hepatic flexure near the liver
4. The transverse colon is usually over 18 inches in length and extends across the
upper abdomen to the splenic flexure
5. The descending colon, usually less than 12 inches long extends from the splenic
flexure downwards to the start of the pelvis
6. The sigmoid colon, which is S-shaped and measures about 18 inches long. It extends
from the descending colon to the rectum

Rectum. The rectum is a curved pouch that lies in the hollow formed by the sacrum and
connects with the anal canal at its lower end.

The wall of the colon is composed of four layers (Figure 2):

1. Mucosa - The epithelial (single layer of cells) lining is flat and regenerates itself every
3-8 days. Small glands lie beneath the surface
2. Submucosa - The area between the mucosa and circular muscle layer and is
separated from the mucosa by a thin layer of muscle, the muscularis mucosa
3. Muscularis propria - The inner circular and outer longitudinal muscle layers
4. Serosa - The outer single cell thick covering of the bowel. Similar to the peritoneum,
the layer of cells that lines the abdomen

The colon does not have lymphatic channels in the submucosa between the mucosa and
muscle. This is important because tumors invading into this area do not have lymphatic
channels to metastasize (spread) through

Pathology

Cancer of the colon and rectum is the most common cancer of the bowel. (Figure 3)

In men, it is the third most common lethal cancer next to cancer of the lung and prostate

In women, it is second only to lung and breast cancer as a cause of cancer related death

Cancer of the colon and rectum is common in patients over age 50 and steadily rises after
that. Americans have about a five percent chance of developing colorectal cancer if they live
to 70 years of age

The onset of familial and hereditary forms of colorectal cancer occurs at a much earlier age

Diverticulosis is a condition that is common in western society. It increases with age and is
present in approximately 75% of Americans over the age of 80
1. It is associated with diverticula, which are protrusions of the innermost lining of the
colon through the muscular outer layers of the colon wall
2. The diverticula can become inflamed, a condition called diverticulitis, which can
cause perforation of the bowel abscess, bleeding, obstruction of the bowel or fistulae
of the colon (a communicating hole between the colon and other organs such as the
small bowel, urinary bladder, vagina or skin)

There may also be inflammatory bowel disease (called Crohn's disease}, ulcerative colitis or
ischemic (decreased blood supply) colitis. These conditions result in inflammation of the colon
that can involve the entire thickness of the colon wall (Crohn's disease, ischemic colitis) or
only the mucosa, the innermost lining of the colon (ulcerative colitis)

Figure 3 - Colon cancer as seen through a

colonoscope. The cancer completely

surrounds the bowel wall leaving only a
small lumen (opening). This cancer
caused bowel obstruction.
History and Exam
Symptoms
that may not require that may require
surgery
surgery
rectal bleeding
bleeding
perforation of the
abdominal pain
bowel wall
vomiting
fistulae
pain that is severe
and persistent
Diagnostic Tests

Chemical testing of the stool for the presence of blood. The test is performed by placing a
swab of stool on porous paper. A chemical is added that checks for the iron in red blood cells.

X-ray of the abdomen (flat plate). A simple X-ray of the abdomen may show pockets of fluid
indicating problems with the colon.

Barium Enema. A solution of barium sulfate is given as an enema. The barium solution coats
the inside of the bowel and any abnormality present. X-rays highlight the abnormalities.

CT of abdomen. A CT scan is obtained of the abdomen looking for a mass, fluid pocket or
abnormal air/fluid level.

Colonoscopy/Sigmoidoscopy/Anoscopy. A short tubular instrument with a handle may be used

to inspect the anus and adjacent rectum. A flexible tube attached to a fiber optic light source
and television camera is passed into the rectum to the sigmoid colon (sigmoidoscopy). A
longer flexible scope may be used to investigate the entire colon (colonoscopy). If a lesion
such as a polyp is found, it may be biopsied or removed. (see Colonoscopy, Figure 4)

Virtual CT colonoscopy. This is a new technique. The patient is given a cathartic and enema
to clear the bowel of feces. Air is used to inflate the bowel. A CT scan is then taken of the
bowel. A special computer program then begins at the rectum and follows the inside of the
bowel as it twists and turns. This technique may detect a lesion but a biopsy cannot be
obtained. (Figure 5)

Figure 4 - Endoscopes used

in the diagnosis of colon
lesions. The anoscope is a
short tubular instrument that
examines the anus and
rectum. The rigid
sigmoidoscope can extend
into the sigmoid colon while
the flexible sigmoidoscope
extends to the descending
colon. The flexible
colonoscope can be used to
investigate the entire colon.

Figure 5 - Virtual CT
colonoscopy demonstrating
two polyps in the transverse
colon.

Indications

Colectomy (removal of the colon) can be carried out for various diseases including:
1. Cancer: Removal of the colon and rectum is the main stay of treatment for cancer. It
can be curative or palliative at which time the surgery is performed to relieve
symptoms. Colon surgery for cancer may be combined with other forms of treatment
including radiotherapy and chemotherapy
2. Polyps: Removal of the colon is performed for a condition called Familial
Adenomatous Polyposis that is associated with numerous polyps in the colon at a
young age. It carries a very high incidence of colon cancer and hence requires the
removal of the entire colon to prevent malignancy
3. Colitis: Colon resection may be performed in patients with inflammatory bowel
disease (ulcerative colitis and Crohn's disease) with persistent, intractable pain and
failure of medical treatment, intestinal obstruction, fistulae, bleeding, perforation, and
marked dilatation of the colon
4. Diverticular disease: Colon surgery is performed in patients with diverticulitis (acute
inflammation of the diverticuli) with or without abscess formation, persistent profuse
bleeding, or perforation of the bowel wall
5. Other conditions that may necessitate removal of the colon include

Intestinal obstructions

Perforation of the colon wall

Volvulus in which the bowel is twisted on itself causing obstruction

Ischemic colon (lack of blood supply to the colon)

Toxic megacolon (massive dilatation of the colon)

Fistulae between the colon and other organs such as the bladder or vagina

Removal of the colon may be carried out as a scheduled procedure or as an emergency in life
saving situations such as severe bleeding or perforation of colon

The extent of removal of the colon varies depending on the site of the disease. In the removal
of the colon for cancer, all the lymph nodes that drain the tumor are also removed

Adjuvant Therapy (Complimentary Therapy)

Clinical trials are underway to determine the role of neoadjuvant therapy in treatment of
carcinoma of the rectum

Neoadjuvant therapy for rectal tumors usually consists of external beam irradiation (X-ray
radiation therapy) to the affected area plus administration of chemosensitizing agents
(medication that enhances the effect of radiation)

Neoadjuvant therapy appears to result in a lower local recurrence rate following surgery. This
downstages the tumor (shrinks the tumor mass) and more often allows preservation of the
anal sphincters (muscles) in lower rectal tumors avoiding permanent colostomy

Neoadjuvant therapy appears to improve survival. A standard of care for these rectal lesions
that includes neoadjuvant therapy should be forth coming in the next few years

Surgical Procedure

Before surgery, the bowel must be prepared to decrease the incidence of infection.
Preparation begins a few days prior to colon surgery. The patient is placed on a low residue
diet for 2-3 days prior to surgery and on liquids the day before surgery, with complete fasting
from the midnight before surgery

The patient is usually admitted to the hospital on the day before surgery and is given some
purgatives to cleanse the large bowel along with antibiotics

Intravenous fluids are given on the night before surgery to avoid dehydration resulting from
the diarrhea due to the cleansing action of the purgatives

Intravenous antibiotics are usually administered just before surgery to reduce the incidence of
infections. They may be continued after surgery.

The procedure is usually done under general anesthesia

An incision is made in the abdomen. The incision is carried through the wall of the abdomen
to expose the bowel

The diseased portion of the colon is identified and that part of the colon and its blood supplied
is divided and removed. The ends of the bowel are sutured together by hand with individual
sutures. (Figure 6) Care is taken to identify the ureters, small intestine and other organs so as
to avoid injury to these organs

In the last ten years, special instrumentation has greatly simplified the procedure. A stapler
placed across the colon seals the colon on each side of the stapler and then cuts the colon
between the staples. Likewise, a different type of stapler staples the anastomosis together.
(Figure 7)

After surgery, the abdominal wound is usually closed although in cases with colon perforation,
the wound may be left open and closed at a later date

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Sometimes, an emergency operation may need to be performed to remove the colon in cases
with perforation of the colon, bleeding or diverticulitis
1. In such cases, a colostomy is usually performed
2. When a colostomy is performed the colon is brought out through a separate incision
in the abdominal wall and sutured to the skin
3. Feces are then excreted in to a bag attached to the skin
4. This may be temporary or permanent

Tumors or lesions in the ascending colon can be treated by an operation to remove the last
part of small bowel, the ascending colon, hepatic flexure, and a small part of transverse colon
(right hemi-colectomy)

In a similar fashion, lesions of the descending colon and sigmoid are dealt with by left hemicolectomy (removal of descending colon and adjoining parts of sigmoid colon, splenic flexure
and part of transverse colon) and sigmoid colectomy respectively

After removal of a segment of colon, the two ends of the bowel are joined together (called an
anastomosis). Tumors in the upper part of rectum and lower part of sigmoid colon are dealt
with by an operation called an anterior resection, wherein the rectum and sigmoid colon are
removed and lower end of the rectum is joined to the colon

Removing the entire rectum and part of the sigmoid colon (abdomino-perineal resection) is
used in the treatment of tumors low in the rectum
1. The end of the remaining colon is brought out as a colostomy
2. Polyps or tumors that are very low in the anal canal can sometimes be resected from
below, through the anus (transanal resection of the tumor)

Complications
In addition to the routine complications of any general anesthetic, there can be complications as a
result of the colon surgery. These include:

postoperative bleeding

dehiscence or breakdown of the anastomosis

recurrence of tumor

wound infection

urinary or respiratory infections

deep vein thrombosis with or without pulmonary embolism

urinary retention

adhesions with bowel obstruction

injury to the ureter

obstruction at the anastomosis site

After Surgery

The recovery period after colon surgery is widely variable. It usually involves a stay in the
hospital from 3-10 days in uncomplicated cases

The patient will have a catheter in the urinary bladder for a few days and will be given
adequate pain relief, intravenous fluids, antibiotics etc

For patients who do not have any oral intake for several days, nutrition may be provided
intravenously or through a tube in the stomach or bowel

The function of the bowel is monitored closely to await the passage of gas and stool after
surgery

The patient then gradually begins to take liquids by mouth and solid food later on, following
which they will be discharged home

After Care

The patient resumes normal activity in 1-3 weeks

Heavy exertion and lifting is avoided weights for 4-6 weeks

If a colostomy is required, the patient receives instruction on its care

Laparoscopic Colon Surgery

Because of recent advances in instrumentation, colon surgery can also be performed using
the laparoscope

This method employs the use of a long tube containing a light and lens system for
visualization and special instruments for manipulating the bowel through small incisions in the
skin called ports

This surgery, however, is still in its development phase and is not widely done

Laparoscopic colon surgery can be performed for various elective indications of colon
removal other than cancer

In cancer surgery, there have been instances of recurrence of tumor at the site of the
laparoscopic ports. (There is, however, an ongoing study by the National Institutes of Health
(NIH) to further evaluate the use of laparoscopic colon surgery for cancer.)

Stapling instruments similar to that used for routine colectomy have been developed for the
laproscopic approach. (Figures 7)

Laparoscopic colon surgery enhances the prospect of speedy recovery of the patient as the
incisions used are small and the patient experiences minimal postoperative pain. These
patients may be discharged home earlier than routine open colon surgery