Abdomino Perineal Resection of the Rectum
What is it?
Some of the lowest part of your bowel, the rectum, is diseased and has to be taken out. Because the disease is so near 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 the motions. Also you might get complications from the underlying disease. A new opening for the bowel is made in the wall of your tummy, a colostomy. The waste runs into a special stick-on plastic bag.
You will have a general anaesthetic and will be asleep for the whole operation. A cut about 35 cm (15") long is made in the skin and muscle of the tummy wall. Sometimes the operation is done with minimally invasive techniques such as laparoscopic (keyhole) or robotic surgery. The lower bowel within reach is freed from it’s bed. Another cut is made around the back passage, which is also freed. 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 colostomy. The wounds are stitched up. You should plan to leave hospital about 2 weeks after the operation.
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 risk of the disease causing further problems. Radiotherapy and chemotherapy can be combined with surgery but dont often cure the problem on their own. The surgeon can talk to you about this.
Before The Operation
Stop smoking and 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 that these are under control. Check the hospital’s advice about taking the pill or hormone replacement therapy (HRT).
If you are on blood thinning medications such as warfarin or plavix or clopidegral you should stop these well before your surgery. Your doctor must be made aware of these tablets.
Bring your relevant scans or X-Rays in to hospital with you.
If you have a heart condition or are of a certain age you may be required to have a heart test such as an echocardiogram prior to your surgery.
You maybe required to take bowel preparation to clean the bowel prior to your admission. Please follow the instructions carefully.
You may be asked to see a stomal therapist prior to, or on admission, to hospital. This person is specially trained in siting and managing colostomy bags.
Check you have a relative or a friend who can come with you to hospital, take you home and be with you for the first week after the operation.
Bring all your tablets and medicines with you to hospital. On the ward you may be checked for past illnesses and may have special tests, ready for the operation. You will be asked to fill in an operation consent form. Many hospitals now run special pre-admission clinics where you visit for an hour or two, a week or so before the operation for these checks. You will meet the stoma nurse who will help you through the operation and afterwards.
After - In Hospital
You will have a dressing on your wounds and a drainage tube nearby, connected to a plastic bag. You will have plastic drainage tubes coming out of the skin near your lower wound. The wounds are painful for two or three days and you will be given injections and, later, tablets to control this. You may have a fine tube in your back to help control the pain. Ask for more if the pain is still unpleasant.
A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. Do not make important decisions during that time.
You will probably have a fine drainage tube in the penis or front passage to drain the urine from the bladder until you are able to get out of bed easily. You should be eating and drinking normally after about 4 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. Sometimes 7 or 8 stitches are put across the wound to add strength. Stitches and clips are removed after about 8 days. The drain tube is removed after 4 days or so.
Your stoma nurse will show you how to manage your colostomy. You can wash the wound area as soon as the dressing has been removed. Soap and tap water are entirely adequate. Salted water is not necessary.
You will be given an appointment to visit the Outpatient Department for a check up about one month after you leave hospital. The stoma nurse will keep in contact with you at home. The nurses will advise about sick notes, certificates, etc.
After - At Home
You are likely to feel very tired and need rests 2-3 times a day for a month or more. You will gradually improve so that by the time 3 months has passed you will be able to return completely to your usual level of activity. At first, discomfort in the wound will prevent you from harming yourself by too heavy lifting. After 3 months you can lift whatever you like. You can drive as soon as you can make an emergency stop without discomfort in the wound, ie. after about 4 weeks.
You can re-start sexual relations within 3-4 weeks, when the wound is comfortable enough. There may be some damage to the sex nerves following the operation. The surgeon will talk to you about this.
You should be able to return to a light job within 8 weeks. Some heavy jobs may not be suitable because of the colostomy.
Complications are unusual but are rapidly recognised and dealt with by the nursing and surgical staff. If you think that all is not well, please ask the doctors and nurses.
You will be given injectable medication and stockings to avoid blood clots occurring in the leg. If pain or swelling occurs in either leg please alert nursing and medical staff immediately.
Chest infections may arise, particularly in smokers. Occasionally the bowel is slow to start working again. This may take a week or more. Your food and water intake will continue through the vein tubing.
Sometimes there is some discharge from the drain by the wound. This stops, given time. Wound infection is sometimes seen. This settles down with antibiotics in a week or two. Aches and twinges may be felt in the wound for up to 6 months. Sometimes the lower wound is slow to heal. Sometimes the stoma is troublesome. Sometimes there is some damage to the bladder and sex nerves.
The operation should not be underestimated. Some patients are surprised how slowly they regain their normal stamina. Virtually all patients are back doing their normal duties within 3 months.
You will be surprised how good the modern appliances are. Your social life should not be affected by the operation. The stoma nurses will keep in touch with you always.
We hope these notes will help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.