The surest way to cure a patient with colorectal cancer is to ensure that the cancer removing radical operation is performed with the best technical skill possible. In the colon, radical or wide resection of all cancer and potentially cancer bearing areas is not a problem as the colon is very mobile. In the lower rectum the rigid pelvic side walls and the anus may make wide radical operations a big challenge. A well performed total mesorectal excision (TME) however is very important as this removes the entire rectum and all cancer bearing lympho-vascular and fatty tissues surrounding the lower rectum resulting in the best cure rate for rectal cancers.

Such wide resection however may result in increased bowel frequency, urgency and the occasional incontinence which may result in severe disability especially in older people. These post operative problems however may be mitigated by a colonic-J pouch. The addition of a J pouch to the anastomotic configuration instead of joining the divided end of the colon straight to the anus gives an anal function like that of normal people. J pouches should be done in all colo-anal anastomosis or ultra low anterior resections which is what the TME operation is.

Local excision is where the cancer and immediate surrounding tissues only are removed. There are only two situations where this operation should be considered. Firstly the cancer must be very small and investigations must show that it had not spread beyond the rectal wall. This is because the surrounding lymphatics are not removed and if there are cancer cells therein the cancer will recur later to dire consequence. Radio-chemotherapy therefore is added to the local excision to decrease the risk of cancer cells being left behind in local excision in appropriate cases. The second situation that local excision is used is when a patient is unfit to undergo major surgery. In such a case a major operation may kill the patient. Therefore, local excision is used to palliate symptoms only. Cure is not the main aim in these cases. Local excision through the anus may be performed either manually or via telescopic techniques such as trans-anal endoscopic microsurgery (TEM). Manual local excision techniques can be laborious and inexact but TEM is technologically more exact and enables good visualization and precise surgery to be performed. Local excision techniques preserve anal function best compared to radical operations and most patients have hardly any change of anal function preand post operatively.

Abdomino-perineal resection where the anus is removed is needed in less than 5 percent of all cases of colorectal cancers nowadays. It is needed when the rectal cancer is growing onto the anal muscles or if there is inadequate space below the cancer to allow for an adequate clear margin of at least 1-2 cm. If the patient persists in preserving the anus; cancer cells may be left behind and recurrence is definite. In this instance, removal of the anus is the best way to cure the patient.

Nevertheless we now have the technology to reconstruct a new anus even when the anus must be removed totally. Stimulated graciloplasty or the reconstruction of a new anus uses the gracilis muscle of the thigh to create a new anus. This muscle is first wrapped around the end of the colon sewn to the skin opening forming a new anus. Constant electrical stimulation is then applied via an implanted battery to enable the gracilis to function like normal anal muscle. Some patients but not all will have excellent results following stimulated graciloplasty.

Every sort of colorectal resection and anastomosis can now be performed by the laparoscopic approach. Patients however should be aware that methods of laparoscopic surgery vary widely. Surgery is based on science but its performance is based on art; as surgery is skill based on science. Each surgeon must therefore not just possess the best scientific knowledge and training but also ability and talent in order that skill can be honed to bring the best results for patients committed to his care. Laparoscopic or robotic methods can bring a large improvement not just to the length of wounds but also to greatly improve recovery and hospitalization times and even improve cancer outcomes in the right situations.

At my centre, I believe that each patient should be assessed and treated individually. Every situation should be optimized with the best care available using the right technology applicable to enable the patient and surgeon to obtain the best result possible.