Rectal Cancer

About Rectal Cancer

Rectum is an organ hidden deep in the pelvis (hip bone). Conventional open rectal cancer surgery is difficult due to poor visibility (see image). However, robotic & laparoscopic rectal cancer surgery gives better quality vision to the surgeon. A laparoscopically skilled cancer surgeon can operate using laparoscopy giving superior results to a rectal cancer patient. With laparoscopic rectal cancer surgery, the trauma is much less and that makes the treatment more acceptable to the patient.Robotic surgery is more advanced form of laparoscopy making it easier to perform more complex surgeries, especially for those tumors lying very low in the rectum and after chemo-radiotherapy. Robotic surgery makes it possible to preserve anus in more number of patients.


MBBS, MRCSEd, DNB (Gen Surg),
MNAMS (Gen Surg), DNB (Surgical Oncology),

Fellowship in Laparoscopic and Robotic Onco-Surgery.
Dr Nayak is one of the leading senior Surgical Oncologists (cancer surgeon) of Bangalore. He is one of the pioneers of Laproscopic (laparoscopic) cancer treatment (surgery). He is the Director of Surgical Oncology at Fortis Hospital, Bangalore.

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is a surgical oncologist with interest in minimal access cancer surgeries. He finished his MCh (Surgical Oncology) training from Vydehi medical College and later did fellowship in minimal access and robotic Surgical Oncology. He has special interest in Breast cancers, Minimal access surgical oncology and Cytoreduction and HIPEC procedures. He has won award for best surgical video presentation in National conference and Best Abstract presentation in International conference, Korea.

The Advantages Of Robotic & Laparoscopic Rectal Cancer Surgery Include

What Is Rectal Cancer (Back Passage)?

Large bowel is made of colon and rectum (back passage). The rectum is the final straight portion of the large intestine. It terminates in the anus. The human rectum is about 12 cm long.

Rectum stores our waste before defecation. An intact anal sphincter or muscles is required for holding the waste (feces) till defecation. Tumors of this portion of large bowel are relatively common.

Most common type of cancer is adenocarcinoma. Rare tumors like melanomas, gatro-intestinal stromal tumor (GIST) and lymphomas are also seen in rectum.

Symptoms And Diagnosis

Colonic cancers can come with anemia due to slow loss of blood or with obstruction to bowel. However, these symptoms occur only when the disease is infiltrated locally. Screening methods are available that can detect colonic and rectal cancer before symptoms appear (stage 0). When detected early, these cases can be cured with much simpler surgery.

Often there are no early symptoms of rectal cancer. Screening methods are available that can detect colonic and rectal cancer before symptoms appear. When detected early, these cases can be cured with much simpler surgery.As the cancer advances, rectal cancer symptoms may become more persistent and severe. The development of tumors in the rectum or anal canal may

  • Change the consistency, shape or frequency of bowel movements (constipation or diarrhea).
  • A feeling of not being able to completely empty the bowel is common.
  • Rectal bleeding may make the stool bright red. A bleeding tumor may also change the color of the stools, sometimes making the stool very dark or tarry looking.

Other generalized symptoms of rectal cancer are seen later in the disease. These may include:

  • Pain in the back passage or rectum or abdomen or cramps
  • Feeling bloated or full
  • Change in appetite
  • weight loss, fatigue or tiredness

Rectal cancer is diagnosed by clinical rectal examination and proctoscopy/ colonoscopy. A biopsy is performed during these procedures to prove the diagnosis.

Staging & Treatment

The stage of rectal cancer can only be confirmed after surgical removal of tumor. However, imaging studies like CT scan or MRI scan give good idea about the stage of the disease in many cases.

Surgery is the main treatment of rectal cancer. All the rectal cancer surgeries can be done robotically or laparoscopically with great advantage to the patient.

Stage 0

Stage 0 rectal cancer is when the disease is limited to the innermost lining (mucosa). While performing endoscopy, an endoscopist can exise it completely (polypectomy). When performed properly, this would serve as complete treatment. However, often more extensive surgery (resection) to remove rectal cancers is required (discribed in next session). Surgery can cure cancer at this stage.

Stage I

Stage I rectal tumors are the ones that have spread beyond the inner lining (mucosa) to the second and third layers. The cancer has not spread outside the colon. Standard treatment involves surgery to remove the cancer (described in next session). Additional treatments like chemotherapy and radiotherapy are not usually needed. Aggressive surgery has the potential to cure this cancer. The five-year survival rate for this stage is more than 90%

Stage II

Stage II rectal cancers are larger and extend through the muscular wall and may have invaded other organs, like the bladder, uterus, or prostate gland. However, there is no cancer in the lymph nodes (small nodular structures that are present throughout the body that clear the tissue fluids). Standard treatment is surgical removal of the cancer (described in next session). When this stage is detected before surgery by CT scan or MRI scan, radiation therapy along with chemotherapy (5FU or Capacitabine) is given for better long term results. If not, the same may be given after surgery. The five-year survival rate for stage II is 78%

Stage III

Stage III rectal cancers have spread outside the rectal wall to the lymph nodes (small nodular structures that are present throughout the body that clear the tissue fluids). Lymph nodes are one of the first to get affected by spreading cancer. The treatment involves multiple modalities:

  • Surgery to remove the tumor and all involved lymph nodes (described in next session).
  • Radiation with or without chemotherapy has to be given before or after surgery (your oncologist will decide about the timing). When given before, this may help in reduction of size of the tumor and preservation of anus (Avoiding permanent colostomy and feel normal).

The five-year survival rate for stage III rectal cancer is about 64%

Stage IV

Stage IV rectal cancers are the ones that have spread to far away organs. Usually these include liver or lung. The mainstay of treatment is chemotherapy, but surgery to remove the tumor may also be recommended. Surgery, when performed, is often used to relieve or prevent blockage of the rectum or to prevent rectal bleeding. A curative surgery may be considered in selected cases where all the tumor tissue can be surgically removed (limited number of liver & lung spread). When surgery is possible, the five-year survival rate can be upto 50%.

When surgery is not possible, other options include destroying them with microwaves or heat (radiofrequency ablation) or giving chemotherapy directly into the liver used with embolization (chemoembolization), etc.

Surgeries For Rectal Cancer

The only treatment that can sure rectal cancer is surgery. All other forms of treatment like chemotherapy and radiotherapy can only reduce risk of recurrence of cancer after surgery, but cannot cure the cancer. A number of different surgical procedures are available to treat tumours of the back passage, the choice depending on where the tumour is located:
  • Abdomino-Perineal Resection (APR) is the standard surgery performed for cancers of back passage (rectum). This means an operation to remove the rectum (back passage) and anus (opening to the back passage) are removed with creation of a permanent colostomy (a bag on the abdominal wall collect waste). With present day technique and technology, we can avoid permanent colostomy same cure rates.
  • Avoiding permanent colostomy and feel normal: The greatest fear of patients suffuring from rectal cancers is loss of anus and the need to have a permanent stoma. This changes the self image. Colostomy changes the way you lead your life. Luckily today for many rectal cancer sufferers we are able to save the anus and restore normalcy by using specialized techniques called intersphincteric dissection and ultra low anterior dissection  with colo-anal anastomosis. These surgeries are performed with better results using robotics than with other approaches.
  • Anterior Resection or Low Anterior Resection: This surgery is used for those tumours of the back passage, that are away from the anal muscles (sphincter) those control the anus. The bowel and the back passage are joined together so that the patient can pass motion though the back passage. MACS makes this major surgery less painful and tolerable for the patients (see advantages listed above)