Abdomino-perineal resection of the rectum

Some of the lowest part of your bowel, the rectum, is diseased and has to be taken out. Because the disease is so near to the opening in the back passage, this has to be taken out as well. If the back passage were left in place, you would be unable to control your bowel motions. You might also get complications from the disease.

A new opening for the bowel is made in the wall of your tummy. This is called a colostomy. The waste runs into a special stick-on plastic bag.

Open Surgery

• you will have a general anaesthetic, and will be asleep for the whole operation
• a cut about 10cm long is made in the skin and muscle of the central lower part of the tummy wall the lower bowel is freed from its normal position
• another cut is made around the back passage, which is also freed and the whole of the lower bowel is taken out
• a fresh opening is made in the tummy wall for the remaining bowel which is made into a stoma 
• the wounds are stitched up
• You should plan to be in hospital for about a week.

Keyhole Surgery

• you will have a general anaesthetic, and will be asleep for the whole operation
• 3 small cuts 2cm long are made in the skin and muscle in the central lower part of tummy wall the lower bowel within reach is freed from its bed
• another cut is made around the back passage, which is also freed and the whole of the lower bowel is taken out
• a fresh opening is made in the tummy wall for the remaining bowel which is made into a stoma the wounds are stitched up
• You should plan to be in hospital for about 3-5days

Are there any alternatives?

Doing nothing will lead to bleeding, discharge, pain and possibly a complete blockage of the bowel. Taking out the diseased bowel, but leaving the back passage in place in your case is risky. You would end up with little control of the bowels and a risk of the disease causing further problems.

X-ray treatment and drug treatment on their own are not very good. They may be useful if added to the operation. The surgeon can talk to you about this.

Before - at home

• stop smoking
• get your weight down if you are overweight

if you know that you have problems with your blood pressure, your heart, or your lungs, ask your family
doctor to check these

if you are taking any of the following, check the hospital's advice about taking them:

• the pill
• hormone replacement therapy (HRT)
• aspirin, or
• warfarin

arrange for a relative or friend to:

• come with you to the hospital
• take you home, and
• look after you for the first week after you leave hospital
• bring all your tablets and medicines with you to the hospital

You will meet with the stoma nurse, who will arrange to see you in clinic. She will talk to you about your operation and stoma. We usually recommend that five days before your operation you eat a light diet that is low in fibre. For example fish, chicken, rice and mashed potato. Try to avoid vegetables, fruit, cereals and wholemeal bread. You can drink as much as you like.

• you will be checked for past illnesses.
• you will have special tests to make sure that you are well prepared and that you can have the operation as safely as possible.
• an anaesthetist will also see you, to discuss the type of anaesthetic you will be given. He or she will ask you about chest problems, dental treatment and any anaesthetics you have had in the past.
• the anaesthetist will also discuss different types of pain relief with you.
• if you are not sure about anything, please ask a doctor or nurse for more details. 

You will have a drip to give you fluids while you are not allowed to drink. This is a plastic tube attached to your neck. The doctors listen to your bowel through your tummy with a stethoscope. When they can hear sounds from your bowel or you have passed wind they start to give you oral fluids. This can take a few days. This is gradually increased until you are able to drink as much as you want.

• Once you are drinking normally the drip will come out and you will be able to eat a light diet. 
• you will have a dressing on your wounds and a drainage tube nearby, connected to a plastic bag. This is to drain any blood left from the operation
• the wounds are painful for a few days. You will be given painkillers to control this
• the nurses will help you with everything you need until you are able to do things for yourself
• you will probably have a fine drainage tube (catheter) going into your bladder to drain the urine.  This will be taken out when you are able to get out of bed easily your ward nurse will show you how to manage your stoma and the stoma nurse will oversee this
• You should be eating and drinking normally after about four to six days.
• The wound has a dressing which may show some staining with old blood in the first 24 hours. There may be stitches or clips in the skin. Stitches and clips are removed after about 7 to 10 days. The drain tube is removed after about 2-4 days.
• You can wash as soon as the dressing has been taken off. You can bath and shower as normal.
• You will be given an appointment for a check-up at the outpatient department about six to eight weeks after you leave hospital.

The nurses will tell you about things like sick notes and certificates. The stoma nurse will keep in contact with you at home

The anaesthetic drugs will make you sleepy, slow, clumsy and forgetful for about 24 hours. Do not make important decisions during this time.

After your open operations - at home

You are likely to feel very tired and need rests two or three times a day for a month or more. You will gradually improve so that after three months you will be able to return to your usual level of activity. At first discomfort in the wound will stop you from harming yourself by lifting heavy things. After three months you can lift as much as you used to lift before your operation.

You can drive as soon as you can make an emergency stop without discomfort in the wound. This should be after about six to eight weeks.

You can restart sexual relations within three to four weeks when the wound is comfortable enough. There may be some damage to the sex nerves after this operation. Some studies suggest that it happens in up to 50% of cases. The surgeon will talk to you about this.

You should be able to go back to a light job within eight weeks. Some heavy jobs may not be suitable because of the colostomy.

After keyhole Operation - at home

After keyhole surgery the recovery time is much quicker than with the open operation. But caution still should be paid to heavy lifting and driving.

Possible complications

As with any operation under general anaesthetic, there is a very small risk of complications to your heart and lungs. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way. This brings the risk for such complications very close to zero.

This is a major operation and complications can happen more often compared with other operations of the bowel. When they do happen, they are quickly recognised and dealt with by surgical staff. If you think that all is not well, please let the doctors or nurses know.

You may get a chest infection, particularly if you smoke. To prevent chest infections it is important to:

• get out of bed as soon as possible
• get as mobile as possible
• co-operate with the physiotherapists to clear the air passages
• The bowel can be slow to start working again and this may take several days
• There can be some discharge from the drain by the wound, but this stops given time.

Wound infection happens more often in any bowel operation compared to other 'clean' operations such as taking out your gallbladder. The reason is that the bowel has many bugs that can cause an infection. This settles down with antibiotics in a week of two.

Very rarely, during the operation, another part of the bowel, bladder or a blood vessel can be damaged. Another operation may be needed to deal with this.

Complications of the stoma are:

• a skin rash
• infection or abscess (a pool of pus) around the stoma
• narrowing, stricture or necrosis (tissue death) of the bowel at or near to the stoma
• a hernia of the colostomy, where the bowel falls through the skin
• These complications happen in 4 to 30% of cases. If you get any of these it is likely that you will need another operation to fix the problem.

You may also have:

• aches and twinges in the wound for up to six months
• slow healing of the lower wound
• trouble with the stoma
• some damage to the bladder and sex nerves

Some patients are surprised how slowly they get back their normal stamina. Nearly all patients are back to normal within three months.

Your social life should not be affected by the operation.

The stoma nurses will keep in touch with you when you are home

We hope these notes will help you through your operation. They are a general guide, and do not cover everything.

If you have any questions or problems, please ask the doctors or nurses.