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Different methods of operating on the colon: Choosing the right procedure for you

What are the different methods of operating on the colon?
Your surgeon may recommend an operation on your colon/rectum (also called colectomy) for several reasons. The most common and dreaded reason is for colorectal cancer. Other reasons include complications of diverticular disease and severe infection (which has become life-threatening). While the operation choice may differ slightly based on the pathology, most colectomy operations follow similar principles. Using colorectal cancer as a guide, there are currently 3 ways to perform colectomy; open (laparotomy), keyhole (laparoscopic) and through-the-anus (transanal).
What is the open (laparotomy) technique?
The open technique is when surgery is performed by making an incision on your abdominal wall to enter the abdomen and remove the colon. This is the oldest technique but has its strong merits when performed well. This method has become less fashionable nowadays because newer techniques use smaller wounds and are associated with less pain and fewer complications of heart problems, chest infection and wound infection.
The commonest way to perform laparotomy is through a vertical incision in the midline. Sometimes, this incision can be as long as from the lower edge of the breast plate to the pubic bone (where the pubic hair is). Usually the length of the incision is only half of this distance. Other ways to perform laparotomy is to use targeted incisions which are oblique incisions in the lower abdomen either on the right or left side in order to directly approach the right or left colon for surgery. Targeted incisions are associated with faster surgery, faster recovery and less pain, but have a slightly increased risk of the wound developing a hernia in the future.
What is the keyhole (laparoscopic) technique?
The keyhole technique is when small (usually 5 to 12mm diameter) ports are inserted into the abdominal wall and surgery is guided by a camera in the abdomen. Narrow instruments are introduced through these ports to allow the surgeon to perform the surgery.  It is important to note that the extent of surgery performed via the keyhole technique is the same as for the open technique and achieves equally good result. It has the added benefit of faster recovery and fewer complications after surgery.
There are several variations to the keyhole technique but the principles of the keyhole technique are essentially the same for each variation. The common variations today are single port, 3-port, 4-port, 5-port, hand-port assisted and robotic assisted laparoscopic surgery. Each surgeon has a preferred technique and the results are best when the surgeon uses the technique he/she is most familiar with. The amount of pain from each variation is about the same.
What is robotic surgery for the colon and rectum?
The robotic surgery technique is unique. It offers 3D views and helps improve depth perception in narrow spaces. The instruments are also more versatile as it has superior range of motion compared to other laparoscopic instruments. This benefit is not obvious in some types of colectomy but its superiority becomes evident when dealing with rectal cancers. The robot allows the surgeon to zoom in and perform surgery up close within the narrow pelvis, something we could not do with the open technique.
What is transanal surgery for the rectum?
Transanal surgery is reserved for surgery in the rectum (which is the last 10-15 cm of the bowel). This technique avoids the problems and complications of surgery from the abdomen but is limited by the narrow access through the anus. It is ideal for dealing with rectal tumours which are pre-cancerous and do not require removal of a long segment of the bowel. It is also well described for very early stage rectal cancers. The tumours within 8 cm of the anus can be easily removed via a simple technique but tumours higher up the rectum require the surgeon to use instruments similar to keyhole surgery instruments, a technique known as transanal endoscopic microsurgery (TEM).
What are the pros and cons of each technique?
Each technique has its unique advantages and risks. It is important to ask your doctor to explain them to you. It is also important to note that the benefits of each technique are closely linked with the experience of the surgeon in performing these operations.
The main advantage of open laparotomy is that it allows full access to all areas of the abdomen. It allows the surgeon to palpate and feel all the intestines and other internal organs for any unexpected abnormalities. However, with good radiologic imaging such as CT scans and MRIs, it is very unlikely to miss these abnormalities nowadays. With a long incision, there is more post-operative pain and the risk of chest and wound infections is much higher compared to keyhole surgery. Furthermore, when the internal organs of the abdomen are exposed to air, the patient will develop more adhesions which may cause bowel obstruction even years later.
Keyhole surgery addresses the problems of open laparotomy by reducing the size of the wounds and exposure of internal organs. As such, patients with keyhole surgery have fewer complications of wound infection, chest infection and faster recovery. Risks associated with age and other medical problems, such as diabetes and heart disease, are less pronounced. Therefore, patients with high risk of complications due to complex medical history benefit more from keyhole surgery, when compared to healthy younger patients who need colonic surgery.
The different techniques of keyhole surgery have similar benefits and choice is dependent on the surgeon’s preference, experience and other disease pathology. These will be explained by your surgeon. The problem with keyhole surgery is that the surgeon would need to have undergone training in keyhole surgery for colorectal diseases and therefore, not all colorectal surgeons are proficient keyhole surgeons. This does not mean they are lousy surgeons.
Robotic surgery has some advantages over keyhole surgery because the surgeon has better visualization with the 3D camera system offering superior depth perception. This is important especially during delicate surgery around the nerves of the pelvis. The increased range of motion of the robotic arms allows the surgeon to perform complex maneuvers in a narrow space while operating on the rectum in the pelvis. However, the advantages of robotic surgery are not as obvious when surgery is performed in the colon as the increased range of motion is not required.
Transanal surgery offers the benefit of not creating a wound in the abdominal wall to perform surgery on the rectum. It is truly “scarless” surgery as everything is performed through the anus. However, access is difficult and this technique is reserved for patients who have a tumour (which is very early cancer) and involves less than 50% of the rectal wall circumference. Patients fulfilling these criteria form fewer than 1% of all colorectal surgery patients.
Which operation is the right one for me?
This is a difficult question to answer as the decision is based on assessing technical factors of surgery (such as size and location of tumour), patient’s fitness for surgery, experience and capabilities of the surgeon and cost. Please talk frankly with your surgeon before deciding which method is the best for you.
Laparotomy (Open Surgery)
  1. Requirements
    • No special equipment required
  2. Pros
    • Can be performed by most surgeons
    • Wide access to all areas of abdomen
  3. Cons
    • Long wound
    • More painful
    • Longer bowel recovery time
    • Higher risk of heart and lung complications
  4. Best option for
    • Large tumours
    • Complex multi-organ surgery
    • Emergency cases with no abdominal scans
Laparoscopy (Keyhole Surgery)
  1. Requirements
    • Surgeon trained in Keyhole Colorectal Surgery
    • Available Keyhole Instruments
    • Good pre-op imaging with CT or MRI scan
  2. Pros
    • Smaller wounds = less pain
    • Faster bowel recovery
    • Lower risk for heart/lung and wound complications
  3. Cons
    • Not every surgeon trained to do Keyhole surgery
    • More expensive as specialized equipment needed
    • Difficult for large tumours or complex multi-organ surgery
  4. Best option for
    • Operation of choice for colon surgery
    • Smaller tumours
    • Elderly patients or patients with other medical problems e.g. diabetes
Robotic Keyhole
  1. Requirements
    • Surgeon trained in Robotic Surgery
    • Available robotic surgery equipment
    • Good pre-op imaging with CT or MRI scan
  2. Pros
    • Better depth perception with 3D visualization
    • Greater range of motion in narrow pelvis
    • Better for preserving crucial pelvic nerves
  3. Cons
    • Very specialized training needed
    • Difficult to perform surgery in different parts of abdomen as robot needs to be re-adjusted many times
    • Most expensive option
  4. Best option for
    • Low rectal surgery
Transanal Endoscopic Microsurgery
  1. Requirements
    • Specialized equipment
  2. Pros
    • No wounds = least pain
    • Fastest bowel recovery time
  3. Cons
    • Specialized equipment costs
    • Only suitable for < 1% of cases
    • Significant risk of bowel leakage requiring second surgery
  4. Best option for
    • Small pre-cancerous tumours of rectum
    • Frail patients deemed too high risk for abdominal surgery
Where can I get more information of these operations?
  1. NHS National Institute for Health and Clinical Excellence (NICE) guidance for laparoscopic surgery for colorectal cancer.
  2. American Cancer Society website health information on colorectal cancer surgery.
If you have feedback or would like to know more about treatment for these conditions, feel free to contact us or make an appointment.