High anterior resection

A high anterior resection is an operation to remove part of the left side of the colon including the upper part of the rectum. This also involves removing the supportive tissue to the bowel including the draining lymph nodes to that section. A join (anastomosis) will then be formed connecting the remainder of the left colon on to the rectum. The join will usually be made with a special stapling device.

How will my surgery be performed?

The aim of colon surgery is to remove the relevant section of bowel with the surrounding lymph nodes in the safest way and with the fastest recovery. For many people we can offer keyhole (laparoscopic) surgery which can speed up recovery. Others may require an open approach meaning a longer incision up and down the middle of the abdomen.

There are many factors which contribute to the decision on surgical technique including location and size of the cancer, obesity, previous surgery and other medical problems. The choice of operation will be discussed with you at the time of consultation.

Keyhole surgery

Keyhole or laparoscopic surgery is where several small incisions are made in the abdomen. The abdomen is then inflated with gas (carbon dioxide) to create a space to work in. Long instruments with fine tools on the end are then used to free up the bowel. Once the bowel has been freed, a slightly longer incision is then made in the lower part of the abdomen to remove the bowel and help make the join.

The benefit of keyhole surgery is usually a faster recovery and less post-operative pain.

Open surgery

Open surgery was the traditional way to perform colon operations. It involves a cut up and down the middle of the belly to remove the bowel and form the join. Whilst keyhole surgery is our preference for some people open surgery is the most suitable technique.

Do I need to take bowel preparation before surgery?

You will usually be given an enema by the nurses when you arrive in hospital prior to your surgery. This is just to clean out the rectum to facilitate the join. You will not usually be required to take oral bowel preparation prior to this surgery. You should have been advised about this during your consultation.

Will I need a stoma?

Most likely not! Most elective high anterior resections can be performed without the need for a stoma. In certain circumstances, depending on pre-existing medical conditions, medications and the reason for an operation, a temporary stoma may be required.

If you suffered a serious complication from the surgery, a stoma may be required.

What can I expect after my surgery?

This will differ a little bit depending on whether the surgery is performed keyhole or open and who the anaesthetist is.

Pain relief

Most people will get local anaesthetic injected around the nerves of the abdominal wall at the time of surgery. This will usually last for several hours. You will also likely have a PCA (Patient Controlled Anaesthesia) to deliver strong pain relief through an IV cannula. You are responsible for pushing a button to deliver the pain relief when you need it. There will also be tablet pain relief available should it be required.

Diet

Most people can at least have fluids and possibly even food the day after surgery. There is plenty of evidence to show that the sooner people start eating, the sooner they recover! If you have nausea after your surgery we will give you medications to manage it and you may need to slow down how much you eat and drink.

Tubes and catheters

You will come out of surgery connected to a few tubes. There will be IV fluids hanging on a pole by the bed connected to an IV cannula. This will usually continue for 1-2 days until you are drinking enough. There will be a catheter in your bladder measuring output of urine. This will often be removed about day 2 once you are able to get out of bed. You will also be connected to oxygen through either a mask or “nasal prongs”.

Preventing clots

Deep vein thrombosis is a serious complication of surgery. In order to reduce this risk you will have compression stockings put on your legs prior to surgery. During surgery you will also have calf compressors on. These will normally be taken off within a day or two after surgery once you are able to walk around. You will also receive a low dose blood thinner injection daily to stop clots. The oral contraceptive pill increases the risk of clots. If you are taking it we will usually recommend stopping it prior to surgery.

Medications

After the operation:

·         You will continue with your usual medications, possibly except for any blood thinners

·         You will be given injections daily to prevent clots in the legs

·         You will receive adequate medication for pain relief and nausea

When you go home:

·         You continue your normal medications unless instructed otherwise

·         You will be given pain relief medication to go home with and take it as needed

·         It is unlikely that you will require any laxatives

How long will I be in hospital for?

Your length of stay can be varied. For keyhole surgery it is typically anywhere from 2-5 days. For open surgery it is usually a bit longer, about 4-7 days. Often the biggest factor preventing discharge is waiting for your bowels to work. This can sometimes take several days.

What will my bowels be like after surgery?

An anterior resection will cause a noticeable change in your bowel habit. Most people will find that they go to the toilet more frequently. It may also be a bit looser than normal. You may also find in the first few months you pass more wind than normal. A lot of these symptoms will settle down over the space of many months or even a year or more.

What are the risks of surgery?

Bowel surgery is major surgery and carries risks. Whilst it is not possible to list all potential complications the following are the more important and common ones:

Bleeding

Bleeding can occur from any surgery. If the bleeding is excessive you may require a blood transfusion.

Infection

Infections can happen in the wound or deeper within the abdomen or pelvis. It may just require antibiotics for the milder infections, or further operations for the more severe infections. There is also the risk of chest infections (pneumonia) and bladder infections (UTI).

Ileus

After any abdominal surgery, the bowels will take a little while to start working again. This can vary from a day to a week or more. For most people, your bowels will normally start to work (pass wind) in a couple of days and then open your bowels soon after. Don’t be concerned if it takes many days for your bowels to work, this is what is termed an ileus. They will work eventually! We encourage you to get out of bed and walk around the ward as this is a very good stimulant for your bowels to start working again.

Anastomotic leak

This is the complication that as colorectal surgeons we worry most about. When a section of bowel is removed we (usually) join the two ends together. This is achieved with either stitches or special staples. There is a chance that the join will not heal successfully and bowel content can leak through the join. The more common joins without the need for a stoma have a risk of approximately 2%. If there is a leak in the post-operative period you may require further surgery and potentially a stoma (bag).

Ureteric injury

The ureter is a tube that runs from each kidney to the bladder and drains urine. There is a very low risk of damage to the ureter during a routine elective bowel resection.

Hernia

Any incision in the abdomen has the risk of weakening over time and forming a hernia. This would usually not occur until at least a year after surgery. You may need surgery to repair it. Rarely does it happen soon after surgery.

Vascular event

Any surgery has the risk of either a heart attack or stroke.

Further surgery

Any complication may require further surgery to correct the problem.

Death

No one likes to talk about this, but major surgery carries a risk of serious complications and death. Factors that can increase the risk are age and pre-existing medical conditions