APPOINTMENT
Original medical visualisation of the colon and rectum with ICG fluorescence
BACK TO HOMEELIXIS · COLORECTAL ONCOLOGY

Colon & rectal cancer

Treatment is planned for the individual. Tumour location and stage, imaging findings, overall health and the patient's priorities all shape the operation. The aim is a safe oncological resection while limiting treatment burden where possible and protecting bowel function and quality of life.

Medical author: Efstratios K. KouroumpasPage updated:
MDT PLANNINGMESOCOLIC PLANE · TMEICG FLUORESCENCE
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SYMPTOMS · TIMELY ASSESSMENT

Symptoms that merit assessment

Colon or rectal cancer may cause no symptoms at an early stage. A persistent, unexplained change in bowel function deserves medical assessment, although it does not necessarily mean cancer.

01

CHANGE IN BOWEL HABIT

New persistent diarrhoea, constipation or a change in bowel frequency.

02

BLOOD OR BLEEDING

Blood in the stool or bleeding from the rectum should be assessed.

03

INCOMPLETE EMPTYING

A feeling that the bowel has not emptied or a constant urge to pass stool.

04

ABDOMINAL SYMPTOMS

Persistent pain, cramps, pressure or bloating without a clear explanation.

05

WEIGHT LOSS

Unexplained weight loss or reduced appetite.

06

POSSIBLE ANAEMIA

Fatigue, breathlessness or dizziness may reflect blood loss and anaemia.

These symptoms can have many benign causes. Diagnosis requires clinical assessment and, when indicated, endoscopy or imaging. Screening remains important even when there are no symptoms.

01 · FROM DIAGNOSIS TO PLAN

One oncology plan, designed for one patient

Treatment is organised step by step. In rectal cancer, high-quality MRI and multidisciplinary review come before any definitive decision.

  1. 01PRECISE STAGING

    Colonoscopy and biopsy, CT of chest–abdomen–pelvis, CEA and dedicated pelvic MRI for rectal cancer. Molecular or genetic testing when indicated.

  2. 02MULTIDISCIPLINARY REVIEW

    Surgeon, radiologist, pathologist, medical oncologist and radiation oncologist build one shared strategy rather than isolated decisions.

  3. 03TAILORED OPERATION

    Resection extent, laparoscopic or open access and reconstruction are selected according to location, stage and individual anatomy.

  4. 04PATHOLOGY & FOLLOW-UP

    Structured specimen assessment, review of final stage and an organised plan for adjuvant treatment or surveillance.

02 · COLON CANCER

A different colectomy for each location

There is no single operation for the entire colon. Resection follows the vascular and lymphatic anatomy of the segment that contains the tumour.

CME

Oncological colectomy aims for an intact mesocolic-plane resection with adequate regional lymphadenectomy. Formal Complete Mesocolic Excision (CME) with central vascular ligation is not automatic for every patient; it is selected according to tumour location, vascular anatomy and the experience of the surgical team.

Anterior view · R / L: patient's sides

  • Illustrative resection
  • Bowel preserved
  • Illustrative lesion
  • Division points
  • Anastomosis

Schematic illustrations to explain surgery. The extent of resection, reconstruction and possible stoma are individualised. Vessels, mesocolon and lymph-node clearance boundaries are not shown.

01Caecum · Ascending colon

What is removed

RIGHT HEMICOLECTOMY — What is removedCaecum · Ascending colon. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative resection. Division points. Anterior view · R / L: patient's sides.RLIleumRectum

How the bowel is joined

RIGHT HEMICOLECTOMY — How the bowel is joinedCaecum · Ascending colon. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative reconstruction: Ileocolic anastomosis. Anterior view · R / L: patient's sides.RLIleumRectum
Illustrative reconstructionIleocolic anastomosis

RIGHT HEMICOLECTOMY

Removal of the right colon and its lymphatic field, followed by an ileocolic anastomosis.

MESOCOLIC PLANE · INTRACORPOREAL ANASTOMOSIS
02Hepatic flexure · Proximal transverse

What is removed

EXTENDED RIGHT HEMICOLECTOMY — What is removedHepatic flexure · Proximal transverse. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative resection. Division points. Anterior view · R / L: patient's sides.RLIleumRectum

How the bowel is joined

EXTENDED RIGHT HEMICOLECTOMY — How the bowel is joinedHepatic flexure · Proximal transverse. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative reconstruction: Ileocolic anastomosis. Anterior view · R / L: patient's sides.RLIleumRectum
Illustrative reconstructionIleocolic anastomosis

EXTENDED RIGHT HEMICOLECTOMY

A wider oncological resection when tumour position requires coverage of adjacent vascular and nodal territories.

TAILORED VASCULAR APPROACH
03Mid transverse colon

What is removed

SEGMENTAL TRANSVERSE COLECTOMY — What is removedMid transverse colon. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative resection. Division points. Anterior view · R / L: patient's sides.RLIleumRectum

How the bowel is joined

SEGMENTAL TRANSVERSE COLECTOMY — How the bowel is joinedMid transverse colon. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative reconstruction: Colocolic anastomosis. Anterior view · R / L: patient's sides.RLIleumRectum
Illustrative reconstructionColocolic anastomosis

SEGMENTAL TRANSVERSE COLECTOMY

Selected segmental resection with careful planning of perfusion, margins and lymphadenectomy.

MESOCOLIC PLANE · TAILORED EXTENT
04Splenic flexure · Descending colon

What is removed

LEFT HEMICOLECTOMY — What is removedSplenic flexure · Descending colon. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative resection. Division points. Anterior view · R / L: patient's sides.RLIleumRectum

How the bowel is joined

LEFT HEMICOLECTOMY — How the bowel is joinedSplenic flexure · Descending colon. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative reconstruction: Colocolic anastomosis. Anterior view · R / L: patient's sides.RLIleumRectum
Illustrative reconstructionColocolic anastomosis

LEFT HEMICOLECTOMY

Oncological removal of the left colon with reconstruction adapted to bowel length and perfusion.

MESOCOLIC PLANE · ICG PERFUSION
05Sigmoid colon

What is removed

SIGMOID COLECTOMY — What is removedSigmoid colon. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative resection. Division points. Anterior view · R / L: patient's sides.RLIleumRectum

How the bowel is joined

SIGMOID COLECTOMY — How the bowel is joinedSigmoid colon. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative reconstruction: Colorectal anastomosis. Anterior view · R / L: patient's sides.RLIleumRectum
Illustrative reconstructionColorectal anastomosis

SIGMOID COLECTOMY

Laparoscopic oncological sigmoid resection with reconnection of healthy colon to the rectum.

MESOCOLIC PLANE · COLORECTAL ANASTOMOSIS
06Multiple or extensive lesions

What is removed

SUBTOTAL COLECTOMY — What is removedMultiple or extensive lesions. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative resection. Division points. Anterior view · R / L: patient's sides.RLIleumRectum

How the bowel is joined

SUBTOTAL COLECTOMY — How the bowel is joinedMultiple or extensive lesions. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative reconstruction: Ileosigmoid anastomosis. Anterior view · R / L: patient's sides.RLIleumRectum
Illustrative reconstructionIleosigmoid anastomosis

SUBTOTAL COLECTOMY

Removal of most of the colon while preserving a selected distal segment when disease distribution, oncological safety and perfusion permit. Reconstruction is individualised.

EXTENDED ONCOLOGICAL RESECTION
07Diffuse colonic disease · selected indications

What is removed

TOTAL COLECTOMY — What is removedDiffuse colonic disease · selected indications. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative resection. Division points. Anterior view · R / L: patient's sides.RLIleumRectum

How the bowel is joined

TOTAL COLECTOMY — How the bowel is joinedDiffuse colonic disease · selected indications. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative reconstruction: Ileorectal anastomosis. Anterior view · R / L: patient's sides.RLIleumRectum
Illustrative reconstructionIleorectal anastomosis

TOTAL COLECTOMY

Removal of the entire colon with preservation of the rectum and an ileorectal anastomosis when oncologically and functionally appropriate. A different reconstruction or a stoma may be required in other circumstances.

TOTAL COLON RESECTION · INDIVIDUALISED ANASTOMOSIS
08Splenic-flexure lesion · demanding reconstruction

What is removed

SPLENIC FLEXURE & COMPLEX RECONSTRUCTION — What is removedSplenic-flexure lesion · demanding reconstruction. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative resection. Division points. Anterior view · R / L: patient's sides.RLIleumRectum

How the bowel is joined

SPLENIC FLEXURE & COMPLEX RECONSTRUCTION — How the bowel is joinedSplenic-flexure lesion · demanding reconstruction. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific. Illustrative reconstruction: Transverse colon to rectum. Anterior view · R / L: patient's sides.RLIleumRectum
Illustrative reconstructionTransverse colon to rectum

SPLENIC FLEXURE & COMPLEX RECONSTRUCTION

Resection extent and reconstruction — including a transverse-to-rectal anastomosis or modified Deloyers strategy — are selected according to disease distribution, vascular anatomy, perfusion and the ability to create a tension-free anastomosis.

ADVANCED RECONSTRUCTION
03 · ONCOLOGICAL PLANES

CME for the colon. TME for the rectum.

Both principles share one philosophy: remove the tumour together with its natural lymphovascular envelope along clean anatomical planes.

CME · COLON

COMPLETE MESOCOLIC EXCISION

Oncological colectomy follows the embryological mesocolic plane with adequate regional lymphadenectomy. Formal CME and central vascular ligation are used when appropriate for tumour location, anatomy and the individual case.

  • Intact mesocolic envelope
  • Central vascular approach where appropriate
  • Adequate margins and nodal staging
TME · RECTUM

TOTAL MESORECTAL EXCISION

For mid and low rectal cancer, the rectum is removed with the mesorectum intact through a meticulous, nerve-preserving pelvic dissection.

  • Clear circumferential margin
  • Pelvic autonomic nerve preservation
  • Oncological resection with functional priorities
Real intraoperative views of the same operative field under white light and NIR/ICG during lymphatic mapping for sigmoid cancer. WHITE LIGHT · SAME OPERATIVE FIELD.
Real intraoperative views of the same operative field under white light and NIR/ICG during lymphatic mapping for sigmoid cancer. NIR · ICG LYMPHATIC MAPPING.
Real intraoperative recording: lymphatic drainage and nodal mapping during sigmoid cancer surgery. A selective adjunct — not a substitute for indicated oncological lymphadenectomy.
04 · FLUORESCENCE-GUIDED SURGERY

ICG fluorescence: real-time information

Indocyanine green (ICG) is visualised with a near-infrared camera. Different routes and protocols may support lesion localisation, selective lymphatic mapping or perfusion assessment. It does not replace oncological resection or surgical judgement.

HOW ICG WORKS — IN PLAIN LANGUAGE
01 · THE DYE

Indocyanine green (ICG) is a fluorescent dye used as an additional imaging tool during surgery.

02 · THE ADMINISTRATION

The route depends on the purpose: intravenous administration for perfusion assessment, or local/peritumoural administration under a dedicated protocol for lymphatic mapping.

03 · THE NIR CAMERA

A near-infrared camera detects the signal and displays it in real time. This is fluorescence, not fluoroscopy, and uses no ionising radiation.

04 · THE INTERPRETATION

The finding is interpreted alongside anatomy and other intraoperative information. Dose, timing, haemodynamic state and camera settings can alter the image.

01
BEFORE SURGERY

Marking & localisation

In selected cases, endoscopic submucosal ICG marking before laparoscopy can support lesion localisation. Fluorescence imaging of liver metastases uses different, dedicated protocols and is not illustrated here.

02
DURING ONCOLOGICAL RESECTION

Selective lymphatic mapping

Depending on the protocol, peritumoural administration may visualise lymphatic drainage. This is a selective adjunct; it does not replace indicated oncological lymphadenectomy or determine resection extent on its own.

03
BEFORE & AFTER ANASTOMOSIS

Perfusion assessment

Intravenous ICG allows assessment of blood flow at both bowel ends before they are joined and, where appropriate, after the anastomosis is complete. The image may support a safer transection point.

05 · RECTAL CANCER

From local excision to complex pelvic surgery

Distance from the sphincter, depth of invasion, MRI findings and response to preoperative treatment determine whether the best strategy is local excision, TME, sphincter-preserving reconstruction or a different pathway.

TME

Sphincter preservation is an important goal, but never at the expense of oncological margins. Each decision follows complete staging, MDT review and an honest discussion about function, the possibility of a temporary or permanent stoma and the alternatives.

SCHEMATIC RESECTION TERRITORY
PLANNED RESECTIONBOWEL PRESERVEDLESION SITETRANSECTION LINEANASTOMOSIS

Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific.

01Selected early lesions
SCHEMATIC RESECTION TERRITORY: TEM / TAMIS · LOCAL EXCISIONSelected early lesions. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific.

TEM / TAMIS · LOCAL EXCISION

Transanal excision for carefully selected low-risk cT1N0 tumours or complex polyps. It provides no nodal staging; adverse histology may require subsequent radical resection.

ORGAN-PRESERVING · SELECTED cT1N0
02Upper rectum
SCHEMATIC RESECTION TERRITORY: HIGH ANTERIOR RESECTIONUpper rectum. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific.

HIGH ANTERIOR RESECTION

Removal of the upper rectum with oncologically adequate partial mesorectal excision (PME) and colorectal anastomosis.

PME · ANASTOMOSIS
03Mid and low rectum
SCHEMATIC RESECTION TERRITORY: LOW ANTERIOR RESECTIONMid and low rectum. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific.

LOW ANTERIOR RESECTION

TME with reconnection of the colon to the remaining rectum, often protected temporarily with a diverting ileostomy.

TME · SPHINCTER PRESERVATION
04Very low rectum
SCHEMATIC RESECTION TERRITORY: ULTRA-LOW / COLOANAL ANASTOMOSISVery low rectum. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific.

ULTRA-LOW / COLOANAL ANASTOMOSIS

Reconstruction close to the anal canal when safe oncological margins and acceptable expected function can both be achieved.

ULTRA-LOW · COLOANAL
05Selected very low tumours
SCHEMATIC RESECTION TERRITORY: INTERSPHINCTERIC RESECTIONSelected very low tumours. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific.

INTERSPHINCTERIC RESECTION

Removal of part of the internal sphincter with coloanal reconstruction only when the oncological findings and baseline function make it appropriate.

ISR · SELECTED INDICATIONS
06Very low tumour or technically demanding pelvis
SCHEMATIC RESECTION TERRITORY: TaTME · CECIL TWO-TEAMVery low tumour or technically demanding pelvis. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific.

TaTME · CECIL TWO-TEAM

TaTME changes the access route, not the required oncological extent of TME. It is reserved for selected patients in specialist centres with structured training and proctoring, institutional governance and outcome audit, because of its learning curve and technique-specific risks.

TWO-TEAM · SPECIALIST GOVERNANCE
07When the sphincter cannot be preserved
SCHEMATIC RESECTION TERRITORY: ABDOMINOPERINEAL RESECTION / ELAPEWhen the sphincter cannot be preserved. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific.

ABDOMINOPERINEAL RESECTION / ELAPE

Radical removal of the rectum and anus with a permanent colostomy when sphincter-preserving surgery is not oncologically safe.

APR · ELAPE
08Locally advanced or recurrent tumour
SCHEMATIC RESECTION TERRITORY: EN BLOC MULTIVISCERAL RESECTIONLocally advanced or recurrent tumour. Schematic orientation only — not an operative plan for an individual patient. Tumour position, vascular anatomy, resection extent and reconstruction are patient-specific.

EN BLOC MULTIVISCERAL RESECTION

Complex multidisciplinary removal of adjacent organs in selected cases where complete oncological clearance remains a realistic goal. The simplified diagram shows the pelvic resection field; adjacent organs are not depicted.

MULTIDISCIPLINARY PELVIC SURGERY

Protective ileostomy for rectal cancer

In selected patients, a protective loop ileostomy is created after low anterior resection. Stool is diverted into a pouch to reduce the load on the low bowel join while it heals.

Anterior view · R / L: patient's sides

Before: tumour and illustrative resection

Protective ileostomy for rectal cancer — Before: tumour and illustrative resectionBefore: tumour and illustrative resection. Rectal tumour Anterior view · R / L: patient's sides.RL1IleumRectum

After: bowel join and ileostomy

Protective ileostomy for rectal cancer — After: bowel join and ileostomyAfter: bowel join and ileostomy. Low colorectal anastomosis. Protective loop ileostomy. Two openings in the same ileal loop. Stool flow into the pouch. Anterior view · R / L: patient's sides.RL234IleumRectum
  1. Rectal tumour
  2. Low colorectal anastomosis
  3. Protective loop ileostomy
  4. Collection pouch

Stool flow into the pouch

Two openings in the same ileal loopProximal opening: stool outlet. Distal opening: continues towards the colon.AB
Two openings in the same ileal loop

AProximal opening: stool outlet

BDistal opening: continues towards the colon

Schematic example after low anterior resection. A protective ileostomy is not needed for every rectal tumour. It is usually intended to be temporary; reversal is considered after healing has been assessed and when it is safe. It does not eliminate the risk of an anastomotic leak.

Patient information: NHS · Cancer Research UK

07 · DECISIONS THAT MATTER

Questions that should be answered before surgery

Technique is only part of the decision. Every patient should understand why a strategy is recommended and what it may mean for life after surgery.

01Will the operation be laparoscopic?

A minimally invasive approach is preferred when technically and oncologically appropriate. Open surgery remains the right option for some very large or locally invasive tumours, for emergency presentations and for anatomically complex cases. Safety and completeness come before incision size.

02Will I need a stoma?

Most planned colectomies do not require a permanent stoma. A very low anastomosis may need a temporary diverting ileostomy. An end colostomy is required after abdominoperineal resection and may be the safest option after a Hartmann procedure or another non-restorative resection, particularly in obstruction, perforation or another emergency, or when frailty and other medical conditions make an anastomosis unsafe. The decision is individualised and, whenever possible, discussed before surgery.

03Can rectal cancer be managed without surgery?

In strictly selected patients with a complete clinical response after total neoadjuvant therapy (TNT), a Watch & Wait strategy may be discussed. This is not passive observation: it requires an expert MDT, rigorous criteria and intensive long-term surveillance.

04How is the exact operation selected?

By tumour location, stage, vascular anatomy, sphincter function, previous surgery or radiotherapy, other medical conditions and the patient's priorities. The same diagnosis can require a different plan in two different people.

EVIDENCE · STANDARDS · TRANSPARENCY

The standards behind this page

The page is structured around current guidance and quality standards from international surgical organisations. External links open the original source material.

01ASCRS · Management of Colon CancerClinical Practice Guidelines · 2022OPEN SOURCE02ASCRS · Management of Rectal CancerClinical Practice Guidelines · 2020OPEN SOURCE03ASCRS · Management of Rectal CancerClinical Practice Guideline Supplement · 2023OPEN SOURCE04SAGES · Fluorescence-Guided SurgeryICG Guidelines · 2025OPEN SOURCE05ACS · National Accreditation Program for Rectal CancerMultidisciplinary quality standardsOPEN SOURCE06NHS · Bowel CancerSymptoms, assessment and screeningOPEN SOURCE

This page provides general information and does not replace personalised medical assessment. The indication, extent and technique of each operation are decided after full review of the individual case.

ELIXIS · NEXT STEP

A clear plan starts with the complete picture

Bring your colonoscopy, histology, CT and — for a rectal tumour — pelvic MRI to the appointment. For electronic transfer, contact the practice first so that a secure method can be provided; do not send medical records by ordinary email. The options, benefits and limitations can then be discussed.

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