Doctors in the Division of Colon and Rectal Surgery at Mayo Clinic's campus in Arizona specialize in the surgical treatment of disorders of the colon, rectum and anus. They perform hundreds of operations each year, largely using minimally invasive techniques.

Employing innovative approaches, Mayo Clinic surgeons offer a complete spectrum of services, including major abdominal surgery, anorectal surgery and endoscopic procedures. Innovative procedures include robotic surgery, transanal endoscopic microsurgery and sacral nerve stimulation to treat fecal incontinence.

Enhanced recovery after surgery

The enhanced recovery after surgery (ERAS) approach involves specific processes of care that help you recover as quickly as possible after surgery. It involves teamwork among surgeons, anesthesiologists and nursing staff to maintain and restore nutrition, activity and bowel function postoperatively.

ERAS elements include:

  • Preoperative counseling
  • Shortening the preoperative fast
  • Pre-emptive pain control including NSAIDs and nonopioid oral analgesics
  • Minimizing IV fluids during hospitalization
  • Avoidance of opioid pain medications
  • Aggressive movement out of bed, including walking on the day of operation
  • Faster initiation of diet

The Division of Colon and Rectal Surgery at Mayo Clinic has used ERAS since 2013. With its introduction, we have noted shortened lengths of stay and increased patient satisfaction. Often patients can be discharged two or three days after a laparoscopic bowel resection. Applying ERAS requires a higher level of vigilance on the part of the operating team. Patients need to be counseled appropriately regarding the potential for issues that may arise after discharge. Older patients, people with multiple health concerns, and those undergoing extensive open surgery may need a longer duration of care.

Robotic surgery for rectal cancer

Until recently, operations for rectal cancer were performed using an incision in the abdomen (laparotomy), leaving half of all patients with a permanent colostomy. In the past 15 years, colorectal surgeons have begun using minimally invasive techniques — including robotic surgery — to treat colon and rectal cancers and sphincter-sparing techniques to avoid a colostomy for rectal cancer. The robotic platform offers a greater level of precision, stability and 3-D optics than does conventional laparoscopy.

The Division of Colon and Rectal Surgery at Mayo Clinic has offered robotic surgery to patients with rectal cancer since 2013. We use robotic surgery selectively, primarily in patients for whom conventional laparoscopic surgery is predicted to be more difficult than usual. The benefits of this experience extend to other areas of the surgical practice, and include the ability to partner with surgeons in other disciplines to perform multivisceral operations.

Single-incision laparoscopic surgery

Single-incision laparoscopic surgery (SILS) represents the next frontier in minimally invasive colon and rectal surgery. Classic laparoscopic colorectal surgery usually involves a small midline incision, as well as three to four additional smaller incisions for the insertion of surgical instruments. SILS involves only a 4- to 5-centimeter midline incision at or just above the navel. SILS can be used in partial colectomy, proctectomy, proctocolectomy and ileoanal pouch procedures. Patient outcomes and satisfaction with SILS have been outstanding, and Mayo Clinic is among the most experienced facilities offering this technique.

Transanal techniques

A wide variety of techniques are available for removal of tumors in the rectum, including traditional transanal surgery, transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS). The selection of the approach used depends on the tumor size and position, and the needs of the patient.

With traditional transanal surgery, a small tumor in the very distal anorectum can readily be removed with the use of a retractor and standard instruments.

Patients with larger tumors, and those whose tumors approach the midrectum, are better candidates for a TAMIS. With this technique, a flexible port is placed transanally, and a laparoscope is used to accurately remove tumors up to 30 to 40 percent of the rectal circumference.

For tumors in the upper rectum, the TEM approach is the most powerful. The TEM unit has a longer, fixed retraction that better exposes the proximal rectum. Even tumors located in the upper rectum can be removed full-thickness using this technique.

May 22, 2015