A subtotal colectomy is a major surgical procedure involving the large intestine, or colon, performed to treat severe and debilitating diseases that have not responded to other medical treatments. This operation is considered a last resort when the diseased state of the colon poses a greater risk than the surgery itself. It is intended to alleviate severe symptoms, prevent life-threatening complications, or remove tissue with a high risk of malignancy. The surgery aims to remove the source of the disease while preserving as much gastrointestinal tract function as possible.
What Exactly is Removed
The colon is the longest part of the large intestine, responsible for absorbing water and forming stool. A subtotal colectomy involves removing the majority of the colon, typically leaving the rectum or a small portion of the sigmoid colon intact. The term “subtotal” distinguishes it from a total colectomy (removing the entire colon) or a hemicolectomy (removing only half).
In this procedure, the surgeon removes the ascending, transverse, and descending segments of the colon. This extensive removal is necessary when the disease affects a large area or to reduce the risk of recurrence. The surgeon also removes associated blood vessels and lymph nodes. By leaving the rectum, the surgeon often makes it possible to reconnect the small intestine later, potentially avoiding the need for a permanent external pouch.
Conditions Requiring the Procedure
A subtotal colectomy is reserved for treating severe conditions where medical management has failed or the risk of cancer is high. The procedure is indicated for several conditions:
- Severe inflammatory bowel disease (IBD), specifically Ulcerative Colitis, when medical therapies fail to control inflammation.
- Severe Crohn’s disease that extensively involves the colon or leads to life-threatening complications.
- Familial Adenomatous Polyposis (FAP), a genetic condition causing numerous precancerous polyps, often requiring prophylactic removal due to the near 100% lifetime risk of colon cancer.
- Certain instances of colon cancer, particularly those involving multiple or obstructing tumors.
- Emergent situations requiring control of massive, uncontrolled internal bleeding, severe bowel obstruction, or perforation.
Surgical Techniques and Outcomes
The subtotal colectomy uses two main surgical approaches: open surgery or a minimally invasive technique. Open surgery involves a single, large abdominal incision, typically reserved for complex or emergency cases. The minimally invasive approach, often called laparoscopic surgery, uses several small incisions for specialized instruments and a camera. Laparoscopic surgery generally results in less post-operative pain and a quicker recovery time.
After removing the diseased colon, the surgeon addresses the continuity of the digestive tract using two primary options. The most desirable outcome is an anastomosis, where the end of the small intestine is surgically joined to the remaining rectum. This allows waste to pass through the body’s natural exit, bypassing the need for a stoma. The reconnection is often achieved using specialized surgical staples or sutures.
If a safe reconnection is not possible due to inflammation, infection, or the patient’s health, an ostomy is created. This involves bringing the end of the small intestine (ileum) through a surgically created opening (stoma) in the abdominal wall. An external pouch is then attached to collect the digestive waste, resulting in an ileostomy. This ostomy may be temporary, allowing the body to heal before reversal, or it may be permanent.
Recovery and Adjustments After Surgery
Recovery typically requires a hospital stay of three to seven days, often shorter with a laparoscopic procedure. During the initial post-operative period, patients are encouraged to begin walking (early mobilization) to prevent complications and stimulate bowel function. Pain is controlled, and diet is gradually advanced from clear liquids to soft foods as the digestive system recovers.
Long-term adjustments are necessary because the colon’s primary function of water absorption has been removed. Patients with a successful anastomosis will experience more frequent and liquid bowel movements, initially four to eight times per day. This change is managed through dietary adjustments, avoiding irritating foods, and taking supplemental fiber or anti-diarrheal medication. Patients with a permanent ileostomy must learn stoma care, including how to empty and change the appliance, with instruction from a specialized nurse.