The colon, also known as the large intestine, is a 4-6 foot long tube that sits at the bottom of the digestive tract. The lowest 6 inches of the colon are the rectum. The semi-liquid food waste from the small intestine travels directly into the colon. It becomes more solid as it moves into the rectum. Once in the rectum, the waste is stored until the next bowel movement.

Colorectal disease is quite common today, with more than 500,000 colon surgeries performed on adult patients in the United States on a yearly basis. There are many diseases that may require surgery. These include colon cancer, diverticular disease, gastrointestinal bleeding, inflammatory bowel disease such as Crohn’s disease or ulcerative colitis, intestinal polyps, large bowel obstruction, trauma, and bowel rupture.

Colon or rectal cancer

It is important to have a screening colonoscopy, starting at age 50 for most patients. This procedure detects polyps, which can be removed during the colonoscopy. Over time these polyps can develop into cancer. Appropriate testing is done to determine the stage of cancer, which includes colonoscopy, CT scans, and blood work. Whether or not you need chemotherapy or radiation before or after surgery depends on the stage of the cancer, the location of the cancer, and the final analysis of the tumor that is done by the pathologist after the cancer is removed. The type of surgery that is done to remove cancer depends on where the cancer is located in the colon or rectum. Depending on a patient’s individual circumstances, they may also be considered as candidates for sphincter preservation surgery in order to treat the cancer while ensuring bowel continuity.Your surgeon will discuss the type of surgery you need at your office visit.

Diverticular disease

The colon is a smooth tube. Diverticula are outpouchings in the wall of the colon. These most commonly occur in the sigmoid colon. These can develop due to factors such as low fiber diet, age, and obesity. Contrary to what was previously thought, it is ok to eat popcorn, nuts, and seeds. The most important preventive tool is a high fiber diet, which is contained in many of those foods. Symptoms of diverticular disease can range from mild abdominal pain and bloating to bleeding or severe infection and perforation. The severity of inflammation can vary and can potentially affect nearby organs, such as the bladder or vagina. Depending on the degree of inflammation and the frequency of episodes, surgery to remove the sigmoid colon may be indicated.

Gastrointestinal bleeding

Bleeding that comes from the colon is usually from diverticular disease but can also be from abnormal blood vessels in the colon.

Inflammatory bowel disease: Crohn’s Disease and Ulcerative Colitis

These are complex autoimmune diseases and managed in conjunction with a gastroenterologist. Crohn’s disease can affect any part of the intestinal tract from the mouth to the anus. Ulcerative colitis affects only the colon. Surgery is necessary when medications no longer control symptoms or if the patient is suffering from blockages, bleeding, or perforation. The kind of surgery can range from taking out the part of the colon or intestine that is involved to creating a stoma. This involves making an incision in the abdominal wall where the intestine is opened and the intestinal contents can empty into a bag that is placed onto the abdominal wall. Anal surgery for Crohn’s disease can involve management of anal fistula, using methods like a seton, an endorectal advancement flap, or a LIFT procedure, in order to connect the rectum to the buttocks. In some such surgeries, surgeons will offer patients botox injections to expedite the healing process.

There are two approaches for colon surgery: open surgery and minimally invasive surgery, which includes laparoscopic or robotic surgery. The doctor considers each patient’s diagnosis and state of health to determine which approach will be best for him/her.

Open surgery

Open surgery is done by creating an abdominal incision called a laparotomy. It is a bigger incision that is more invasive and requires more recovery time. This allows for access to the entire colon and abdomen. Part or all of the colon can be removed through this incision, based on the planned operation.

Minimally invasive surgery

Minimally invasive surgery is done using small incisions. Laparoscopic surgery is done with specialized instruments held by the surgeon. Robotic surgery is done by attaching a robot to the instruments and the surgeon directs the instruments from a console. There are different indications for each approach and the surgeon will determine which is the best for each patient.

Part or all of the colon can be removed. Depending on why you are having surgery, the intestines can be reconnected with or without a stoma.

Right hemicolectomy: the ascending colon is resected.

Left hemicolectomy: the descending portion of the colon is resected.

Extended left/right hemicolectomy: in addition to the above, a portion of the transverse colon is resected.

Hartmann’s procedure: the sigmoid colon is resected but the colon is not reattached. The rectal stump is closed and a colostomy is made.

Total colectomy: the entire colon is removed, but the rectum is left in place.

Subtotal colectomy: nearly the entire colon is removed, and the rectum is left in place.

Total proctocolectomy: the entire colon and rectum are removed.

Sigmoidectomy: the sigmoid colon is resected, this can include part or all of the rectum.

Stoma: can be made of small intestine (ileostomy) or colon (colostomy). An incision is made in the abdominal wall and the intestine is opened here. A bag is placed on the abdominal wall and the intestinal contents empty into the bag.

Transanal excision: a growth or polyp can be removed from the anus during an operation known as transanal excision. This can be done using an anoscope for lesions that are very close to the anus. Transanal minimally invasive surgery is done by inserting a special port into the anus and using special long instruments to reach a lesion that is higher in the rectum.

The day before surgery your surgeon will often have you drink a special liquid mixture to clean out the colon. You may or may not be given antibiotics to take as well. You may need special testing to evaluate your overall health prior to undergoing surgery, such as a routine heart and lung checkup. Any specialists involved in your care may also be asked to evaluate you prior to surgery.

Patients usually stay in the hospital 4-10 days after surgery. During recovery, you will first start on a liquid diet. This will slowly be advanced until you are eating regular food. It is important to be out of bed sitting in a chair and walking around the wards in order to regain your strength after surgery and prevent blood clots. You will also be given a special breathing apparatus called an incentive spirometer to work on expanding and strengthening your lungs after surgery. You may also be given a special regimen of medications for pain management. The goal of these medications is to reduce the amount of narcotic medications that you will need to take after surgery, as narcotics cause constipation.

Patients can resume driving once they are no longer taking pain medicine and usually fully resume normal activity within 1-2 months. The doctor specifies further instructions to help patients recover in the best way possible. The appropriate postoperative management is determined by your surgeon based on your overall health, underlying condition, and type of surgery being performed.