Surgical innovations in colorectal cancer

Since 1823, when a practitioner named Reybard was credited with performing the first colon resection, we have seen great progress in colon cancer surgery; based on a better understanding of the disease and its behaviour, and the many advances in safe and innovative surgical techniques by pioneering surgeons.

Surgery continues to be the treatment most likely to cure colorectal (bowel) cancer. Different surgical approaches are used depending on the stage and size of the cancer, its location in the colon or rectum, and whether the cancer has spread to other parts of the body. Other treatment options include radiotherapy and chemotherapy either alone or in combination.

As part of raising awareness of bowel cancer we catch up with our expert colorectal surgeons from the HCA Healthcare UK network to find out more about the innovation driving cancer surgery today.

The most traditional form of colon cancer surgery is known as open colectomy. This surgery is performed through a single long incision in the abdomen and for many years this remained the mainstay of colorectal surgery. 

As the end of the 20th century approached we saw an increase in minimally invasive, or laparoscopic colorectal surgery as an alternative method to open surgery. This is often referred to as keyhole surgery. As opposed to the single long incision used in open surgery, in a laparoscopic-assisted colectomy the surgery is performed through many smaller incisions using special tools. A tiny video camera is put into one of the incisions to help the surgeon see the colon.

When compared with traditional open surgery, the advantages of laparoscopic surgery can include reduced blood loss during the operation, smaller incisions which reduces the trauma on the abdominal wall, reduced recovery time, reduced pain after surgery and faster return of bowel function - while maintaining equivalent cancer outcomes. For this reason, increasing numbers of colorectal cancer patients are undergoing laparoscopic surgery. But that doesn’t mean it’s the right option for everybody. The decision should made after an informed discussion between the patient and the surgeon.

The adoption and rising popularity of laparoscopy into surgical clinics paved the way for another advancement in colorectal surgery, the use of robotic devices to aid surgical procedures.

Robotic surgery is another form of minimally invasive colorectal surgery in which we use a robotic system, called the da Vinci® Surgical System. The robot is controlled by the surgeon using a console, providing increased visibility and a more precise range of motion than the human hand and wrist. Compared to traditional techniques, this minimally invasive approach is likely to cause less damage to surrounding tissue and nerves, significantly reducing a patient’s hospital stay and risk of infection. Straight instruments in laparoscopy make it difficult for the surgeon to reach narrow areas and can cause significant tissue trauma. The robotic instruments have wrist motion and can turn like the human hand, they are controlled with a computer delivering precision and accuracy and minimal tissue trauma, leading to enhanced recovery and minimal complications.

Robotic surgery reduces the need for a colostomy after cancer resection and therefore fewer patients need second operations and can avoid living with a stoma longer-term, it also reduces complications such as incisional hernia and obstruction. This surgery is also associated with better lymph gland clearance which can result in improved survival.

Above all else, the aim of surgical treatment is to completely remove the primary tumour, regardless of the technique. For some patients open surgery remains the best way to achieve that goal, however for many this can now be achieved through a far less invasive procedure, and the recovery benefits that brings.

Most colorectal cancers start in the inner surface of the bowel wall, but in some cases they can spread to the abdominal cavity and affect the surface which is called the peritoneum. These cancers are difficult to treat and require a multi-disciplinary team who specialise in treating advanced colorectal cancer.

Surgery has not traditionally been used to treat colorectal cancer once it has spread to the peritoneum and patients have been treated with systemic chemotherapy alone. However, high quality research has now shown that Cytoreductive Surgery (CRS) is extremely effective at treating peritoneal tumours and can offer the chance of cure. This is then combined with a form of intraoperative chemotherapy called Heated Intraperitoneal Chemotherapy (HIPEC) to kill off any cancer cells left in the abdomen.

Cytoreductive surgery is performed by specialist peritoneal tumour surgeons to remove any visible tumour deposits. Following this, HIPEC is inserted into the abdomen and circulated for around 90 minutes. It is given in a higher dose to conventional chemotherapy and drained at the end of the procedure.

There are only two designated specialist centres in the UK who are expert in this form of treatment; at The Christie we have treated over 1,000 patients using Cytoreductive Surgery and HIPEC. Whilst it’s not appropriate for every patient, for those whose cancer had spread to the peritoneum it can be very effective.

There are many factors that contribute to determining the most appropriate surgery for each individual patient. These are discussed at a specialist Multidisciplinary Team meeting by consultant surgeons, oncologists, radiologists and other healthcare experts.

Each patient is advised on the options available to them and given the information they need to make an informed decision about their care.