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Abdomino-perineal excision of rectum

Before you agree to have your bowel operation it is important to know all you can about it. The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your choice of treatment for bowel problems with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.



What is the problem?

Some of the lowest part of your bowel, called the rectum, is diseased. It is probably causing bleeding, and the passage of mucus and loose motions. You may have a feeling of something still in the bowel after you have passed a motion. There may be some pain.


The diseased part of your bowel needs to be taken out. Because the disease is so near the anus, this has to be taken out as well. If the anus were left in place, you may be unable to control the motions and you may have complications from the underlying disease. We will make a new opening for the bowel, called a stoma, in the wall of your abdomen. This is permanent, as you will no longer have a rectum and anus. Here the new opening is called a colostomy, because the part of the bowel we use is called the colon. Your motions will run into a plastic bag stuck-on to your abdomen.


What are the rectum and anus?

The lower bowel runs from the left side of the umbilicus down into the pelvis. In the pelvis the bowel is called the rectum. The rectum opens from the body as the anus. The part of the body around the anus is called the perineum.

Abdomino-perineal 2

A circular muscle, called a sphincter, opens and closes the anus. If the sphincter muscle is damaged, control of the motions is lost; this is called faecal incontinence, or just incontinence.


In males, the rectum runs behind the bladder, prostate gland and the urethra. In females, the rectum runs behind the uterus and vagina. If the uterus has been removed, the rectum lies next to the bladder and the female urethra.


The nerves that control the bladder and penis and the ureters, which bring urine from the kidneys to the bladder, are all close to the rectum.

Abdomino-perineal 3

What has gone wrong?

It should be clear from the tests that you have had what disease there is in your rectum. The most common disease is a bowel cancer. This looks like a warty swelling or an ulcer inside the rectum. It may be narrowing or blocking the rectum.


The tests also show what type of bowel cancer it is, exactly where it is, how big it is, whether it is free from the surrounding tissues and whether there are any signs of spread elsewhere in the body.


There are also more rare causes, such as inflammatory bowel disease, which has not responded to treatment, or changes in the lining of the rectum that may turn into cancer if left, called pre-cancerous changes.


The aim of the operation

The aim is to remove the diseased part of your rectum together with your anus. Nearby lymph glands are also taken out for examination to check for any spread of the disease. We do the operation using 2 incisions. One is in the abdomen to free off the rectum from above. The other is in the perineum to free off the lower rectum and anus.


Both wounds are made at the same time; this is called an abdomino-perineal excision. We also make the colostomy at the same time.


The benefits

The operation will get rid of the bleeding, loose motions, and mucus. We remove enough rectum, anus and other tissue to minimise the chance of any cancer coming back.


The operation should reduce the chance of a cancer spreading elsewhere in the body. Extra treatment with radiotherapy or chemotherapy may be helpful for this. The benefits of the operation should easily outweigh the disadvantages of having a colostomy.


Are there any alternatives?

Because we remove the rectum and anus, the remaining lower bowel cannot be stitched to the skin wound in the perineum, as you would not be able to control the motions. There would be no sphincter to control the opening. There are no devices at present that can take the place of the sphincter muscle, although there are ongoing trials. It may take several years to find out if this is a safe and reliable technique. One such device is the Acticon Neosphincter Anal Prosthesis. You can find out more details at www.clinicaltrials.gov. The National Institute for Clinical Excellence (NICE) issued guidance on artificial anal sphincter implantation in June 2004 (see www.nice.org.uk).


If we remove the rectum, but not the anus, joining the remaining lower bowel to the back passage may still not give you control of your motions. There would also be a higher risk of the cancer coming back.


If the cancer is high enough in the rectum the surgeon may suggest attempting to remove it, leaving the anus in place. S/he could then join the lower bowel to the anus; this operation is called an anterior resection of rectum. If, at operation, the cancer were found to be too low for this, then the surgeon would have to go ahead and remove the anus.


Simple trimming of the cancer with an electric cautery or a laser may give good relief from symptoms in a person who is not fit enough for major surgery. It may be possible to place a metal tube, called a stent, across a cancer that is obstructing the colon. Often, having radiotherapy or chemotherapy before or after the operation would be helpful in this case.


Sometimes the upper part of the operation can be done using keyhole surgery, called laparoscopic surgery. This would mean four or more one-inch long cuts in the abdomen instead of one long one. You should discuss the various options with your surgeon.


What if you do nothing?

If you do nothing your bowel symptoms will get worse. The cancer may completely block the rectum. The cancer may spread into other parts of the pelvis, such as the bladder or vagina. It may press on the ureters, stopping the urine flow or on the veins taking blood from the legs, causing the legs to swell. It may spread to the rest of the body.


Author: Mr Michael Edwards FRCSEng FRCSEd. Consultant general surgeon.

© Dumas Ltd 2006

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