Robotic anterior resection and high anterior resection

What is it?

An anterior resection refers to the removal (‘resection’) of the rectum and parts of the colon using an approach through the abdomen. This can be done using a surgical robotic system. A high anterior resection or sigmoid colectomy is a similar operation, but the rectum is removed only partially (the ‘upper part’ of the rectum and the sigmoid colon). The bowel is usually reconnected, in rare cases we choose to install a colostomy (‘Hartmann’s procedure’).

Why is it done?

There are a few reasons why you might be offered this operation. Most commonly it is performed for cancer of the rectum, but it can also be necessary for other diseases of the rectum or the sigmoid colon, such as inflammatory disease (colitis or proctitis), diverticular disease, fistulas (inflamed channels) between the rectum/colon and the bladder and other organs.

How does it work?

Up to 5 small instruments are inserted through small cuts into the abdominal cavity. The abdominal cavity ins inflated with CO2 gas to create a ‘working space’. Blood vessels leading to the colon and rectum are identified and carefully divided and sealed. The section of bowel that is to be removed is freed up by dividing connective tissues. Then, the bowel is divided using specifically designed stapling devices, and the bowel is removed through a small incision in the lower abdomen (similar to a small caesarean section scar). Finally, the two ends of the bowel are reconnected using yet another stapling device.

How long does it take?

The operation lasts 2-5 hours depending on the complexity.

Is it painful?

You won’t feel any pain during the operation. When you wake up from the general anaesthetic, you should be pain-free and appropriate pain medicine is given throughout your journey to ensure that you will not feel any or only minimal pain.

Do I need a general anaesthetic (GA) or can it be done under local?

You will need a general anaesthetic. These procedures cannot be done under local or regional anaesthetic. In most cases we will however offer a spinal tap in addition to the GA, as this will help to reduce pain medicine requirements during and after the operation.

How can I prepare for the operation?

Preparation is very important and often underestimated. The success of the operation depends broadly on three things: the quality of surgery, the underlying disease and your fitness. I will always strive to deliver best possible surgical quality and suggest the right operation for you. I some cases we can optimise the underlying disease, e.g. by giving you radiation and chemotherapy before an operation (see cancer treatment) or optimising the medication for a potential heart condition, diabetes or lung disease. In most circumstances you can contribute to a successful treatment by improving your fitness in the days or weeks leading up to the operation. This can be achieved by exercise, going for daily long walks, eating a healthy diet, stop smoking and reduce alcohol intake. We are happy to give you some specific advice how you can achieve these goals.

Do I need to empty my bowels/ take bowel preparation medicine?

Yes. We recommend taking full bowel preparation and a short course of antibiotics the day before the operation (similar to when you have a colonoscopy). This can be done at your home.

Do I need a stoma bag?

A piece of bowel (as an end or a loop) can be brought to the surface of the skin on the abdomen. Bowel contents (faeces, or waste) will be collected in a plastic bag that is attached to the skin and needs to be emptied regularly. If the colon is brought to the surface it is called ‘colostomy’, in case of small bowel ‘ileostomy’. Having a stoma bag can be a terrifying thought. We only perform this procedure if there is a good reason to do it. A ‘colostomy’ can be necessary if there are technical or medical reasons why the bowel cannot be reconnected. In many cases the ‘colostomy’ can be reversed and the bowel reconnected, even several months after the initial operation. For most anterior resections (but only rarely for high anterior resections) we recommend installing a protective ileostomy. This means that a loop of small bowel is brought to the surface of the skin and the waste is diverted into the bag. As a result ‘dirty’ faeces is not passing through a potentially fragile connection of the colon further downstream and will help the healing process. The ileostomy can usually be reversed after 6-8 weeks, but this may take longer if chemotherapy is necessary.

Will my bowels work normally after the operation?

It is a very difficult question and depends on many factors. For most operations you will experience a change in your bowel habits. This can be temporarily, for a few weeks or even months, by having to go to the loo more often, feeling a strong urge to go to the toilet or passing loose stools or small amounts. There is a risk for permanent functional problems (see risks and complications).

What is the risk of complications?

The overall risk of complications depends on the exact nature of your disease, the operation and your fitness. On average there is a 15-20% risk of experiencing any complication. The majority of problems can be categorised as minor (i.e. easy to manage medically), but even minor problems can be uncomfortable for you and delay your hospital stay.

Here is a list of common and rare complications (all % number are averages and may differ significantly for you):

- Wound infection (10%), treated with dressings and/or antibiotics

- Chest infection (2-5%), treated with antibiotics

- Urine infection (2-5%)., treated with antibiotics

- Nausea and vomiting (20%), treated with anti-sickness medication, tube in the stomach

- Anastomotic leak (5-10%), the connection of the bowel is not healing properly and causes an infection, can be treated with antibiotics, in more severe cases another operation may be required.

- Bowel dysfunction. Almost everybody will experience changes in bowel habits (increased frequency, loose stools, urge to go to the loo) and often is temporary. It may take several weeks of months to normalise but is most of the time manageable with minor adjustments to the daily routine. In some cases it can be more severe or even permanent. We will give you some specific information about this as it depends on the exact nature of the operation, your disease and other treatments you may receive.

- Bladder dysfunction (up to %). The function of the bladder can be impaired temporarily or permanently due to reversible or irreversible damage of pelvic nerves. This can result in incontinence or frequent bladder emptying, but is in most cases reversible.

- Sexual function (up to %). Due to potential damage to pelvic nerves your ability to have sex may be impaired. It can result in reduced libido. In men erectile dysfunction and in women dyspareunia (inability to have intercourse) may be a result of this surgery.

- Hernia (1-5\%). Hernias in the area of the surgical incisions are extremely rare.

- For Stoma related complications see Colostomy and Ileostomy

- Bowel adhesions (scars in the abdomen). The risk is minimal due to robotic surgery, but sin rare cases scars can cause passage problems (bowel obstruction)

- General, severe complications, such as a heart attack, clots in the lung vessels or a stroke are very rare, but the risk can be elevated in patients with certain underlying conditions. We will talk to you in detail about those, if applicable.

Is it possible that I don’t wake up after the operation?

The short answer is no, it is not possible. Th long answer is that a general anesthetic is safe and severe complications resulting in death is as low as 1 in hundreds of thousands. Hence, the chances to die on the operating table are almost 0. There is however some mortality as a consequence of this operation. Overall 1% of patients die in the first weeks after this operation, and in most cases, they have experienced a catastrophic complication or have already an extreme high risk profile before the operation. If we have any concerns about this, we will talk to you extensively before making any decision.

What can I eat after the operation?

You will be able to eat and drink immediately after the operation. We usually recommend starting carefully by having small meals and distribute food intake over 5-6 occasions during the day while you are in hospital. At home you should be able to have a normal food pattern again. Depending on your operation you may experience that certain foods (e.g. high-fibre content) will result in loose stools and adjustments may be necessary. We will support you with the input of nutrition specialists should this be necessary.

How long do I have to stay in hospital?

You can leave the hospital as early as two days after the operation. This, however, only applies to a minority of patients who have a high level of fitness, experience no complications and have good support at home by friends and family. In most cases the hospital stay is 5-7 days. If you experience any complications, this can be longer.

When can I return to work?

It depends on the nature of your work and what kind of additional treatment you may require. In the best case you maybe able to do some light office work 2-3 weeks after your coming home, but in the case of more physical work it may take 2-3 months as a minimum.

When can I drive?

You can drive when you are safe to drive. As a ballpark measure, you should be able to make an emergency stop. You should not take any pain medication that may impair your awareness (opioids and similar) when you drive. It is best to check with your insurance if they have any specific rules for driving after surgery.

Does the operation need to be performed with a robot?

No. The same operation can also be performed by keyhole surgery (laparoscopy)