Laparoscopic Anterior Resection

Your Surgeon has advised you to undergo a Laparoscopic Anterior Resection of the rectum. Whilst it is important that you understand what the surgeon means by this operation, you will probably have been told that you may, or may not have to have a COLOSTOMY or ILEOSTOMY (stoma for short) either temporarily or permanently. This is a very frightening concept to many people and the stoma care nurses will give you a booklet explaining what a stoma is and offer you support and practical help.

The operation

The operation is designed to remove part or all of the rectum. This is the bit of the bowel inside you just above your bottom muscles. It is necessary to remove so much bowel because of the way the blood supply looks after the bowel rather than because the disease is extensive. Most of the operation will be done through several very small cuts in your tummy (about 1 cm. or less each) but there will be one slightly larger cut (approximately 6 cms.) which will be made towards the end of the operation through which the excised bit of bowel will be removed.

The rectum is attached to the anal muscles which control the way you have your bowels opened. The diagrams below show the part of your large bowel, near your bottom, which will be removed during the operation. The two ends will be joined together. This is called an ANASTOMOSIS. This is a delicate procedure and it is important that you understand the possible problems you MAY encounter.

Before the operation

• You will probably be admitted to hospital 1-2 days prior to your surgery. You will likely be in hospital between one to two weeks, but it may be a little longer.
• A number of routine tests will be carried out to ensure you are fit for surgery. (If you have a attended a pre-admission clinic you may well have already had these tests)
• You may be given some medicine to clear your bowel and you will be encouraged to drink water. This makes your bowel as clean as possible for the surgeon.
• You will only be allowed to drink clear fluids and you will not be allowed to eat any solid food the day before your operation. Some people, (particularly elderly patients), require a drip before the operation to put fluid into a vein.
• You will have nothing to eat for at least 6 hours prior to your surgery and will be asked to stop drinking shortly before going to theatre.
• An anaesthetist will visit you and discuss your anaesthetic and various methods of post-operative pain relief.
• A stoma care nurse will visit you and mark the best place on your tummy for a stoma to be formed (i.e. where a bag would be positioned) just in case this becomes necessary during the operation.

On the day of your operation.

A nurse will take you to theatre and will also collect you following your operation. After your operation you will be taken into the recovery ward, where you will have your blood pressure and pulse checked. When you are properly awake you will be taken back to the ward.

When you return to the ward from theatre you will have:

• A WOUND on your tummy with stitches, sticky paper dressings or clips, covered with a dressing.
• A needle into a vein (a DRIP) to give you fluids and medicines. YOU WILL NOT BE ALLOWED TO DRINK OR EAT FOR A DAY OR TWO as your bowel has had a 'shock' during the operation and will not work properly at first.
• A CATHETER - a small tube to keep your bladder empty.
• You may have a tube in your nose (A NASO-GASTRIC TUBE) that will keep your stomach empty to stop you from feeling sick.
• You may have a fine tube in your neck (A CENTRAL LINE) to help measure the amount of fluid being put into your body accurately.
• You may have a DRAIN, a small tube to clear away any oozing fluids around the operation site inside. This helps to prevent infection.
• You may have an EPIDURAL (a fine tube in your back) or PCA PUMP (a line into a vein in your arm) which gives you pain relieving medicines. PCA stands for Patient Controlled Analgesia which means you can control how much pain relief medicine is given to you through a vein using a little button switch which you can hold yourself. If you have decided not to have an epidural anaesthetic and to have PCA instead your anaesthetist will have explained how this system works before your operation.
• You may have a stoma appliance (bag) on your tummy.

On return to the ward the nurses will check your blood pressure/pulse and wounds on a regular basis. This is completely normal.

It will take up to a few days to get rid of all these things (except of course a stoma), during which time the nurses will help you to wash, clean your mouth and enable you to move both in and out of bed. If you have a stoma the nurse will help you to learn how to manage the bag.

After the operation

After several days you may feel that you want to pass wind or have your bowels opened. Even if you have a stoma this is entirely NORMAL and you may pass a little old blood or mucus (slime). Please keep the nurses informed.

When you first pass stool again it will be liquid and sometimes it takes several weeks or even months to get used to your new 'plumbing' arrangement. Please be patient with yourself and ask the nurses or doctors if you are worried about anything.

Occasionally some people have to adjust their dietary habits after this operation in order to keep their bowel habit regular. Please talk to one of the nurses or doctors about this if you are in doubt.

Other experiences you may have are:

• A sore bottom
• Constipation and/or diarrhoea
• Frequent small bowel actions
• A lack of control of your bowels which may mark your underclothes.
• ANXIETY due to the whole situation.

THESE ARE ALL EXPECTED OCCURENCES: please talk to one of the nurses about them as they can usually be helped with patience and further information.
It may be helpful for you to do some PELVIC FLOOR EXERCISES. These will enable your bottom muscles to cope with the removal of your back passage. The best one to do is simply tightening up your bottom or trying to stop the flow of urine when you go to pass water.

RISKS and BENEFITS

Risks of this operation are small and much less than the risk of doing nothing but nonetheless this is a major operation and some people (less than 5%) do not survive such surgery.

There are specific risks to laparoscopic surgery (keyhole surgery) which include inadvertent accidental damage to structures inside the tummy such as blood vessels and bowel. This is very rare but if that did happen you may require an open operation with a bigger scar to put things right.
Assuming there are no such problems with your operation the benefits of laparoscopic (keyhole surgery) are such that you would have a much smaller scar on your tummy and you would make a much quicker recovery from your operation. Most people go home after this type of operation within one week.

• All operations carry a risk from anaesthetics but this is minimal due to modern techniques.
• Because of the nature of this particular type of surgery there is a small risk (about 5%) of injury to the bladder and the pelvic nerves that affect sexual function.