General Surgery

Colon Resection - Colectomy

Eight operations share this one word. Which segment comes out decides your hospital stay, whether you wake up joined or with a stoma, and how your bowels work. Written from the randomized trials, for every reason a colectomy is done.

About This Department

Colectomy is one word covering at least eight different operations, and which one you are having depends on which segment of colon is coming out, a single fact that determines how long you are in hospital, whether you wake up joined or with a stoma, and how your bowels behave for the rest of your life. Almost everything else people worry about follows from it. This page is organized around that, and it deals with colectomy for every reason it is done, with the cancer-specific decisions covered separately.

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Find out which segment is coming out and what follows from that

Send the colonoscopy report, the scan reports of abdomen and pelvis, any biopsy result, a note of how many episodes of illness you have had and how they were treated, your blood results, your medication list and details of any previous abdominal surgery. A colorectal surgeon reads the file and tells you which operation is being contemplated, whether a stoma is likely and what would make one necessary. No fee, no obligation, and a coordinator replies in your own language, usually within the same working day.

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Eight operations, one word

Find the row that matches what you have been told, and if nobody has named the operation yet, that is the first question to ask, because every later question on this page depends on the answer to it. The colon is roughly five feet long and it runs up the right side of the abdomen, across the top, down the left side and into the pelvis, so the name of the operation is simply a description of which stretch is coming out.

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The named colectomies, what each removes and what it leaves you with
Operation	What comes out	What you are left with
Right hemicolectomy	The last part of the small bowel, the cecum and the ascending colon.	Small bowel joined to transverse colon. Looser and more frequent stools are common, and the reason for that is explained further down.
Extended right hemicolectomy	The same, plus most of the transverse colon.	Small bowel joined further round to the left. The same function changes, usually a little more pronounced.
Left hemicolectomy	The descending colon on the left side.	Transverse colon joined to sigmoid or rectum. Bowel function usually returns close to what it was.
Sigmoid colectomy	The short S-shaped segment above the rectum.	Descending colon joined to rectum. The commonest operation for diverticular disease and the one most of this page's evidence concerns.
Hartmann's procedure	The sigmoid, with no join made at all.	An end colostomy and a closed-off rectal stump. Reversal is a second major operation and many people never have it.
Subtotal colectomy	Almost all the colon, leaving the rectum behind.	Either an end ileostomy with the rectum left in place, or small bowel joined straight to rectum. The usual emergency operation in colitis.
Total colectomy with ileorectal join	The whole colon, rectum kept.	Small bowel joined to rectum, no stoma. Several loose stools a day is the expected result, and the rectum still needs watching.
Proctocolectomy with a pouch	Colon and rectum both.	A reservoir built from small bowel and joined to the anus, usually in two or three stages with a temporary ileostomy in between.

Why yours is recommended

Cancer is the reason most people assume, and it accounts for a large share of colectomies, but it is far from the only one. Diverticular disease that keeps coming back or that has perforated, ulcerative colitis that no longer responds to drugs, Crohn's disease affecting the colon, a twisted sigmoid that keeps twisting, a polyp too large to lift out at colonoscopy, ischemia, and severe unrelieved constipation with a documented transit abnormality all lead to the same operation. The indication changes very little about the surgery and a great deal about the argument for having it. Which of those you have determines almost nothing about the two or three hours in the operating room and almost everything about whether the operation was the right idea, and that is why the sections below are arranged by reason before they are arranged by technique.

That argument has been tested properly in one setting, which is recurrent diverticulitis. A Finnish trial randomly assigned 90 patients who had been through repeated episodes either to a planned keyhole sigmoid colectomy or to carrying on with conservative treatment, then followed them for four years.

Further attacks over four years occurred in 6 of 38 operated patients (16 percent) and in 34 of 37 treated conservatively (92 percent). Fourteen of the 44 assigned to conservative care ended up having the operation anyway. Yet quality of life scores at four years were 115.3 against 109.8, a difference of 5.54 points with a confidence interval running from minus 2.98 to 14.06, which means the trial could not show a lasting difference in how people felt.

Both halves of that result are true and they point in different directions, which is exactly why the decision belongs to you and cannot be settled by a guideline. Surgery reliably stops the attacks. Whether stopping the attacks makes your life better depends on how bad your life is between them, and the trial's authors said as much, concluding that an operation suits patients whose quality of life is poor while conservative treatment suits those whose scores are already near normal. Ask your surgeon what your score would be, and if nobody has measured it, that itself tells you something about how the decision is being made. The measurement takes a few minutes with a standard questionnaire, it is the same instrument both of the randomized trials used, and it turns a vague conversation about how much the attacks bother you into a number that can be set against the people who were actually studied. Ask for it by name.

Diverticular disease

Two separate questions hide under this heading, and mixing them up is the commonest source of confusion in the clinic. One concerns a planned operation for repeated attacks. The other concerns what to do when the bowel has actually perforated.

The planned operation for repeated attacks

A Dutch trial randomly assigned 109 patients with recurring or ongoing symptoms to elective sigmoid resection or to conservative management, and at five years the quality of life score was 118.2 against 108.5, a mean difference of 9.7 points with a confidence interval of 1.7 to 17.7. Pain scores, physical and mental health scores and general health scores all favored the operated group. Twenty-six of the 56 patients assigned to conservative care, which is 46 percent, had a resection in the end. The price of the operation was visible in the same data, with a leak at the join in 8 patients, meaning 11 percent, and a further procedure needed in 11, meaning 15 percent. That trial was stopped early because recruiting people to be randomized between an operation and no operation proved very difficult, which is worth knowing when you read it. Read alongside the Finnish trial, the honest summary is that surgery buys a real reduction in attacks and a modest improvement in daily life, at the cost of a roughly one in ten chance of a serious surgical complication.

Keyhole or open, when it is planned

Dutch investigators randomized 104 patients to keyhole or open sigmoid resection for diverticular disease and found major complications in the first six months in 9 patients against 23, a difference that reached statistical significance at a probability value of 0.003. Conversion from keyhole to open happened in 19.2 percent, which is higher than most patients expect and reflects how inflamed and stuck-down this tissue can be after repeated attacks. Quality of life was better in the keyhole group at six weeks and the two groups had converged by six months, so the advantage is real and it is front-loaded into the recovery period. Late complications were similar in number, and they were the ones you would expect after any abdominal operation, which is to say incisional hernias, small bowel obstructions and the occasional fistula or stricture. None of that is an argument for insisting on keyhole surgery regardless of what the surgeon finds, because a surgeon who converts when the tissue demands it is doing the right thing, and a unit reporting a conversion rate near zero for inflamed diverticular disease is either selecting very carefully or counting differently.

The emergency choice

If the bowel has perforated and you are ill, the surgeon has three options and they lead to very different lives afterwards, which makes this the single area where an informed patient, or a relative asking on their behalf, can change what actually happens.

Joining the bowel beats Hartmann's for stoma-free survival

A trial randomly assigned 133 patients with perforated diverticulitis to Hartmann's procedure or to sigmoid resection with a join, usually protected by a temporary ileostomy. Stoma-free survival at twelve months was 94.6 percent against 71.7 percent, a hazard ratio of 2.79 with a confidence interval of 1.86 to 4.18. Seventeen of the 64 patients in the join group, meaning 27 percent, needed no stoma at any point. Complications occurred in 44 against 39 percent, a difference that did not reach significance, and deaths were 3 against 6 percent. The authors were clear that this applies to patients who are stable, immunocompetent and under 85.

And the difference persists after discharge

Across 35,774 American patients, 93.5 percent of whom had a Hartmann's, the stoma had been closed within a year in 83.6 percent of those who had a join with a protecting ileostomy against 53.4 percent of those who had a Hartmann's. Median time to closure was 72 days against 115. Complications at the closure operation were less common in the ileostomy group, with an odds ratio of 0.51 and a confidence interval of 0.42 to 0.63.

Washing out instead of resecting is a genuine third option

Where the contamination is pus and no hole can be found, some surgeons wash the abdomen out through a keyhole and leave the colon alone. A Scandinavian trial of 199 patients found severe complications at one year in 34 against 27 percent, a difference that did not reach significance, and a stoma at one year in 14 against 42 percent. The cost was more unplanned reoperations, at 27 against 10 percent, and more deep wound infection, at 32 against 13 percent. A second trial of 83 patients found the risk of needing at least one further operation within two years was reduced by 45 percent, with a relative risk of 0.55 and a confidence interval of 0.36 to 0.84.

Emergency surgery is more dangerous, whatever is done

In a national dataset of 116,920 emergency abdominal operations, colectomy among the commonest, a matched comparison of 11,753 keyhole cases against 23,506 open ones found mortality of 6.0 against 9.1 percent and a median stay of 8 days against 10. Selection explains part of that, since the sickest patients rarely get a keyhole approach. It remains the case that an operation done as an emergency carries a different risk from the same operation done on a Tuesday morning with a prepared bowel, which is the strongest argument for settling an elective decision before events settle it for you.

Ulcerative colitis

Colectomy for ulcerative colitis is not one operation but a sequence, usually spread over a year, and understanding that sequence in advance removes most of the fear from it, because almost nothing that happens in the first stage forecloses a decision in the second.

Stage one takes the colon out and leaves the rectum

A subtotal colectomy with an end ileostomy is the standard first move, whether it is done as an emergency during a severe attack or electively. It removes the diseased organ, gets you off steroids, and leaves every later decision open. In a series of 56 patients having this operation for inflammatory bowel disease, major complications occurred in 39 percent of the emergency cases and 24 percent of the elective ones, with no deaths in either group and a median stay of 13 days against 9. Eighty percent of the emergency operations were done through keyhole surgery.

Stage two builds the pouch

The rectum is removed and a reservoir is built from the last stretch of small bowel and joined to the anus, with a temporary ileostomy protecting it. Pooled figures from the literature put leakage at around 9.5 percent, pelvic infection at 5.5 percent, pouchitis at 18.8 percent and pouch failure at 6.8 percent, rising toward 8.5 percent beyond five years. Those come from a review rather than from a single cohort, so treat them as the shape of the risk instead of as precise probabilities.

Joining small bowel straight to rectum is the other route

It is a smaller operation with no pelvic dissection, and it preserves fertility and sexual function better, at the cost of leaving diseased rectum behind. Across 20 studies and 2,538 patients the join leaked in 3.9 percent, the arrangement failed and had to be converted to a pouch or a permanent stoma in 20.4 percent, and cancer developed in the retained rectum in 2.4 percent. Two thirds of patients rated their quality of life as high. The retained rectum needs a scope every year, indefinitely, and that commitment is part of the choice.

If the diagnosis turns out to be Crohn's

Pouches are sometimes built in patients already known to have Crohn's disease, and the outcomes are worse though far from hopeless. Across the published series, pelvic infection occurred in 13 percent, pouchitis in 31 percent, anal narrowing in 18 percent and a chronic draining track in 28 percent, with overall pouch failure at 15 percent. Average stool frequency was 6.3 times in 24 hours at an average of just under six years. Those figures come from a small number of heterogeneous studies and describe a selected group, so they belong in a conversation with a specialist and not on a spreadsheet.

Two less common reasons

Both of these send a steady trickle of people to colorectal clinics, and in both the evidence is thinner than anyone would like.

A sigmoid that keeps twisting

A long floppy sigmoid can rotate on itself and block, and untwisting it with a scope works in almost everybody, with one French series reporting success in 96 percent of attempts and no complications. Untwisting does nothing about the floppy sigmoid, which is why 23 of the 42 patients in that series who had no operation twisted again. An American analysis of 2,113 admissions found that just under half had a resection during the same admission, and that those who did were readmitted with a further twist significantly less often, with no difference in death but with more complications and a longer stay. That series also reported far higher mortality in the patients who had no surgery, and the authors themselves noted that group was older and less independent, so the gap describes who was chosen for an operation and not what the operation did. The practical question is whether you are well enough for a planned resection once the crisis has passed, and it is a question worth asking before you are discharged rather than after the next episode.

Constipation that will not respond to anything

Removing the colon for constipation is a real operation with real results and it is also the one most likely to disappoint, because it treats a colon that does not move while leaving a pelvic floor that may not open. Nobody should have it without transit studies and an assessment of pelvic floor function first. In a series of 44 women having a hand-assisted keyhole total colectomy, 39 of them, meaning 88.6 percent, rated the result as excellent or good, with a mean stay of 7.6 days and two patients needing a further operation for obstruction. Whether the small bowel is joined to the rectum or the cecum is preserved and joined instead has been compared across five trials and 291 patients, with similar complication rates, a shorter operation and hospital stay for the cecal version and better continence scores, though the published summary reports probability values without effect sizes. The one thing worth insisting on is that somebody assesses the pelvic floor before anybody assesses the colon, because an operation that removes a sluggish colon does nothing at all for a pelvic floor that will not relax, and that mismatch is the commonest reason these operations disappoint the people who have them.

Whether you wake up joined

Every question about stomas comes down to one thing, which is how confident the surgeon is that the join will heal. A leak is the complication that dominates this operation, and the fear of it is what puts stomas on people who might have managed without one. It helps to know how common it actually is.

An audit of 1,347 right-sided resections across 200 centers in 32 countries found an overall leak rate of 8.3 percent. It also found that leaks occurred in 12.1 percent of operations done by general surgeons and 7.3 percent of those done by colorectal specialists, with an odds ratio of 1.65 and a confidence interval of 1.04 to 2.64.

The authors themselves pointed out that general surgeons were operating on a higher-risk group, so this is a long way from a clean measure of skill, and it is still the reason the specialty of the person operating is a fair thing to ask about, whether you are being treated at home or abroad. The question is simply whether colorectal surgery is what they do all week. As for whether you personally will wake up with a stoma, the honest answer is that a planned colectomy in a well person usually ends with a join and nothing brought out to the skin, an emergency in an unwell person often does not, and the surgeon decides in the operating room with the tissue in front of them. What you can do beforehand is ask what would have to be true for a stoma to be made, so that the possibility is not a surprise.

The operation itself

Allow two to three hours for a segmental resection and longer for a total colectomy or a pouch, done through four or five small cuts and one slightly larger one.

The abdomen is entered and inspected. Adhesions from previous surgery are divided, the liver and the peritoneal surfaces are looked at, and the extent of inflammation is assessed. In diverticular disease this is the moment the surgeon discovers how stuck-down things are, and it is where the decision about converting to an open operation is usually made.

The segment is freed from its attachments. The colon is held to the back of the abdomen by a thin membrane, and lifting it away is most of the work. On the left this means finding and protecting the ureter, and on the right it means staying clear of the duodenum, both of which are easier said than done in an inflamed field.

The blood supply is divided. The vessels feeding that segment are sealed and cut. In cancer they are taken at their origin to capture the lymph nodes, and in benign disease they can be taken closer to the bowel, which is one of the few real technical differences between the two.

The bowel is divided and the specimen comes out. Staplers close both ends before anything is cut, and the specimen is lifted out through a small protected opening. Where that opening is placed matters more than it sounds, for reasons covered in the long-term section.

The two ends are joined, or they are not. The surgeon checks that both ends bleed briskly and sit together without tension, then staples or sews them. Where either of those conditions fails, a stoma is made instead, and that judgment is the most consequential one of the whole operation.

The specimen goes to pathology whatever the reason for surgery. Even in diverticular disease an unsuspected cancer turns up occasionally, and the report also confirms that the inflammation was what everybody thought it was. It takes one to two weeks and you should take a copy of it home.

What happens before

Preparation for colectomy is an area where practice varies enormously and where two of the most confidently repeated pieces of advice turned out, when tested properly, to be shakier than expected.

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What is done before a colectomy, and how good the evidence for it is
What is done	What the best evidence says	How to read it
Emptying the bowel and taking oral antibiotics	A randomized trial of 417 patients found wound infection in 7 percent of those prepared and 11 percent of those not, a difference well within chance. Leaks and reoperations were the same in both groups.	Large observational datasets favor preparation and this trial did not. Its authors said the recommendation should be reconsidered. Practice remains divided and either answer is defensible.
A structured recovery program	Across 13 randomized trials and 1,298 patients, hospital stay fell by 2.00 days with a confidence interval of 1.48 to 2.52, wind returned 12 hours sooner, and complications fell with a relative risk of 0.59 and a confidence interval of 0.40 to 0.86.	The best-supported thing on this list. Ask whether the unit runs one, because the individual components are useless in isolation and the effect comes from doing all of them.
The same program after emergency surgery	Across 20 studies covering lower gastrointestinal emergencies, stay fell by 2.80 days and complications fell with a relative risk of 0.66 and a confidence interval of 0.52 to 0.85.	The authors graded this as low to very low certainty. Promising, and thinner than the elective evidence.
Exercise and nutrition training beforehand	A trial in 110 frail patients, average age 78, compared training before surgery with the same training afterwards and found no difference in complications, with an adjusted mean difference of minus 3.2 and a confidence interval running from minus 11.8 to 5.3.	Widely offered and, in this trial, ineffective at the thing it is offered for. It may still be worth doing for other reasons, and it should be described honestly.
Stopping smoking	Not tested in the trials above, and consistently associated with wound healing and leak in the wider surgical literature.	The single change with the clearest rationale that is entirely under your control. Four weeks before is the usual advice.

How the join is made

Surgeons argue about this more than about almost anything else, and some of the arguments have been settled. These are worth reading because they let you ask a specific question instead of a general one.

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The technical arguments about the join, and where each one stands
The argument	Where it stands
Stapled or hand-sewn, for a right-sided join	Settled in favor of staples. Across 6 trials and 955 participants, leaks occurred in 5 of 357 stapled joins and 36 of 598 sewn ones, an odds ratio of 0.34 with a confidence interval of 0.14 to 0.82.
Making that join inside the abdomen or outside it	Four randomized trials covering 399 patients found a smaller incision, less pain on days two through five and a hospital stay shorter by about a quarter of a day when the join is made inside. Leak rates, infections and complications were no different.
Which stapler closes the last opening	No difference found. In the 1,347 patient audit, cutting and non-cutting staplers gave 8.4 against 8.0 percent, and oversewing the staple line changed nothing measurable either way.
Stapling or sewing the pouch join in colitis	Across 31 studies and 8,872 patients, the stapled version had fewer strictures, less obstruction, less pouch failure and better continence, with no difference in stool frequency, pouchitis or leak. The published summary gives directions without effect sizes.
Who is holding the instruments	The largest single difference in that audit, at 12.1 against 7.3 percent between general and colorectal surgeons, with the caveat that the two groups were operating on different patients.

What can go wrong

Colectomy is major abdominal surgery and the list is honest rather than reassuring. Reading it beforehand is what lets you recognize a problem early, which is the only part of this you influence.

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Complications after colectomy, when they show themselves and what is done
Problem	How common	When	What is done
A leak at the join	Around 8 percent for right-sided joins in the international audit, and 11 percent in the Dutch diverticulitis trial.	Usually days three to seven.	Drainage and antibiotics, often a further operation with a stoma. A heart rate that climbs and stays up is the first sign.
Wound infection	7 to 11 percent in the randomized preparation trial, and much higher after emergency lavage.	The first fortnight.	Antibiotics, sometimes opening the wound to let it drain and heal from the base.
The bowel refusing to start	Common, and the usual reason a discharge slips by a few days.	The first week.	A tube through the nose, fluids by drip and time. Recovery programs shorten it.
Injury to the ureter	Uncommon, and more likely in a heavily inflamed left-sided field.	During the operation or in the days after.	Repair, and a stent. Some surgeons place stents beforehand in difficult cases, which is worth asking about.
Clots in the legs or lungs	Raised by any abdominal cancer operation and by inflammatory bowel disease itself.	The first weeks.	Blood thinning injections, often continued after discharge. A long flight taken too soon adds to the risk.
Conversion to an open operation	19.2 percent in the randomized trial of keyhole sigmoid resection for diverticular disease.	Partway through.	Nothing, beyond a longer recovery. It is a judgment about safety and it should be presented as one.

Recovery

Structured recovery programs have shortened this considerably, and knowing what is supposed to happen on each day makes it much easier to tell whether it is happening.

Day of surgery. Sitting out of bed within a few hours and drinking the same evening. Both are deliberate parts of the protocol and neither is a sign of exceptional progress.
Days one to three. Eating, walking the corridor, off the drip. Pain control moves to tablets. The catheter comes out. This is when most people feel worse than they expected to and better than they feared.
Days three to seven. The window when a leak declares itself, and the reason the hospital watches you rather than sending you off. Wind first, then stool. A heart rate that climbs and stays up is the sign that matters most, and it usually appears before the pain changes and well before anybody looks unwell, which is why the nursing observations are taken as often as they are.
Discharge. Four to six nights after a keyhole segmental resection, longer after an open operation, a total colectomy or an emergency. In the series of subtotal colectomies for inflammatory bowel disease the median was 13 days after an emergency and 9 after a planned operation.
Weeks two to six. Tiredness that surprises people. No lifting anything heavy for six weeks, because the extraction wound is the one that turns into a hernia. Desk work at around three weeks after keyhole surgery, physical work at six to eight.
Get in touch about. A rising heart rate, pain that worsens after the third day, a fever, vomiting that will not stop, a wound that reddens and discharges, or a stoma that stops working. The first of those needs to be seen the same day.

Flying home

Around ten to fourteen days after a keyhole segmental colectomy, and longer after an open operation or a total colectomy. That figure is set by one thing, which is that a leak at the join typically announces itself between the third and seventh day and is far easier to manage in the hospital that made the join than in an emergency department that has never seen you. Where the surgery was for cancer, the pathology report adds a second reason to wait, since it takes one to two weeks and it is the document that decides whether you need chemotherapy and who is going to give it to you.

Put two things in the conversation before you book. Clotting risk is raised after any abdominal operation and a long flight adds to it, so ask whether blood thinning injections should continue and for how long, and get the answer written into the discharge summary where your own doctor will find it. And if you are going home with a stoma, ask for enough supplies to last well beyond the journey, plus the exact product codes, because matching a bag and a base plate from a different country's catalogue is a miserable thing to be doing in week two.

Living with a shorter colon

Your colon absorbs water and salt from what the small bowel has finished with, so taking a piece out means less water gets absorbed, and where the piece came from decides how much of that shows in daily life.

Looser and more frequent stools follow a right hemicolectomy. The right colon does most of the water absorption, so its loss shows the most. Most people settle over the first year and a proportion never fully do.
And if it persists, there is a treatable cause worth chasing. Among 45 patients with chronic loose stools after a right hemicolectomy, 82 percent had bile acid malabsorption on testing, against 37 percent of 19 patients without the symptom. Symptoms improved with treatment. This is a cheap test and a cheap drug, and it is missed constantly.
Left and sigmoid resections usually settle close to baseline. The right colon is still doing its job. Some people notice more urgency, particularly when the join sits low.
After a total colectomy with a join to the rectum, several loose stools a day is the expected result. Not a complication and not a failure. Bulking agents, loperamide and timing meals are the usual tools.
With a pouch, plan around five or six bowel movements in 24 hours. The figure of 6.3 in 24 hours comes from a series of patients with known Crohn's disease, which is a harder group than most, so read it as an upper end.
If any rectum was left behind, it needs a scope every year. In the pooled ileorectal series, cancer developed in the retained rectum in 2.4 percent. Annual surveillance is the whole reason that number stays small.

Risks that arrive years later

Two things happen long after everybody has stopped thinking about the operation, and both are worth a sentence at the six week appointment rather than a shock at year three.

Adhesions can block the small bowel

Internal scar tissue forms after any abdominal operation and occasionally kinks the small bowel. In a Californian population study covering 1.6 million patients, the five year rate of adhesive obstruction after partial colectomy was 5.5 percent following open surgery and 2.8 percent following keyhole, with an adjusted hazard ratio of 1.49 for the open approach. The risk was concentrated in the first two years. It is the clearest long-term argument for the keyhole approach, and it applies whatever the operation was for.

The extraction wound can turn into a hernia

The specimen has to come out through something, and that opening is the weak point. Pooling 25 studies and 10,362 patients, a horizontal extraction incision carried substantially lower odds of a later hernia than a vertical midline one, at an odds ratio of 0.30 with a confidence interval of 0.19 to 0.49. Only two of those studies were randomized and the variation between them was high, so treat this as a strong signal instead of a settled fact. A small randomized trial of 40 patients found similar rates at a median of 30 months, and it was far too small to detect a difference.

What to do with both of these

Ask where the extraction incision will be placed and why, since it is a decision the surgeon makes and rarely explains, then respect the six week lifting restriction, which is the only part of hernia prevention that sits in your hands. For adhesions, know the symptoms, which are colicky pain, a swollen abdomen, vomiting and no wind passing, and know that it can happen decades later and is often settled with rest and fluids alone.

Questions to ask

Split them by timing, because the useful ones before the operation are different from the useful ones after it.

Before you agree to it

Which named operation is this, and which segment is coming out. Whether it is planned as keyhole, and what would prompt a conversion, given that conversion ran at 19.2 percent in the randomized trial of diverticular disease. Whether a stoma is expected, what would make one necessary and whether it would be an ileostomy or a colostomy. If you are being offered a planned operation for repeated diverticulitis, ask how many attacks you have actually had, how they were confirmed and what your quality of life score is, because the trial evidence turns on exactly that. If it is an emergency and the word Hartmann's is used, ask whether a join with a protecting ileostomy is possible, since stoma-free survival at twelve months was 94.6 against 71.7 percent in the randomized comparison. And ask whether the surgeon operating is a colorectal specialist. None of those questions is confrontational, all of them have short answers, and a surgeon who has thought about your case will get through the lot in a couple of minutes without needing to look anything up.

Before you leave the hospital

Ask for the operation note and the pathology report, both as documents rather than as a summary. Ask exactly what was removed and how the join was made, because whoever looks after you at home will need that and will not be able to guess it. Ask where the extraction incision was placed. Ask whether blood thinning injections continue and for how many days. If you have a stoma, ask when reversal is planned and what has to happen first, and ask whether anybody has said it might be permanent. If any rectum was left behind, ask when the first surveillance scope is due and who is arranging it. Then ask for a written summary addressed to your own doctor, naming the operation, the findings and the follow-up plan. Ask for all of it on paper and in English, and check before you leave the ward that the documents actually say what you were told in conversation, because a discharge summary naming only the diagnosis and not the operation is common and is close to useless to whoever reads it next.

Reading a quote

No figure appears on this page. What follows is what has to appear in writing before any figure means anything, because colectomy is the kind of operation where the same word covers a four day stay and a three week one.

The operation, by name. Right hemicolectomy, sigmoid colectomy, subtotal colectomy. The word colectomy on its own tells you nothing about what you are being charged for.

How many nights, and the cost of an extra one. A leak declares itself in the first week and turns a five night stay into a much longer one. A quote that has no answer for this has moved the risk onto you without saying so.

Whether conversion to open changes the price. It happened in almost one in five keyhole sigmoid resections in the randomized trial, so this is a common scenario and not a remote one.

Whether an unplanned stoma is included. Along with the supplies, the stoma nurse teaching and enough product to get you home and through the first weeks.

Whether the pathology is inside the number. Every specimen goes to a pathologist whatever the reason for the operation, and that report is a document you need.

Whether a second operation is covered. Reoperation for a leak, and separately the stoma reversal, which is a planned second admission months later and is usually quoted apart.

What is excluded. Packages published by Turkish hospitals and medical travel agencies generally cover transfers, pre-operative testing, surgeon and anesthesia fees, the operating room, the planned nights, pathology, an interpreter and a review before departure, and generally exclude flights, insurance, complications, extra nights, stoma supplies and follow-up beyond the first weeks.

Coming to Istanbul

Twelve to sixteen days covers assessment, the operation and a safe departure for a planned segmental colectomy in somebody arriving with the workup done. Send these things in this order and the first reply will be a useful one.

Colonoscopy report, and any biopsy result. If a scope could not be completed, say why, because that changes what has to happen and in what order.
The scan reports, in writing. The report itself and not a summary of it. For diverticular disease, every scan from every attack, since the number and severity of episodes is the whole basis of the decision.
A plain account of your episodes. How many, how severe, whether any needed a hospital stay, drainage or antibiotics through a drip, and how you feel between them. That last part is the one nobody writes down and the one the randomized evidence turns on.
Your drugs, in full. Steroids, biologics, immune-suppressing drugs, blood thinners and anything for diabetes. Several of these change the timing of surgery and some change the safety of making a join at all.
Blood results and any previous operations. Recent bloods, plus a note of every previous abdominal operation, because adhesions from an old one lengthen this one and raise the chance of converting to open surgery.
Your questions, written down. Send them with the file so the surgeon answers them in the first consultation instead of the last.

One coordinator holds your file from the first message to discharge, and the international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish, with other languages arranged on request. Ask in your first message if you would prefer a female physician. Someone can stay overnight with you on the ward, where the rooms carry a companion bed, and meals from the hospital kitchen cover halal, vegetarian and diabetic diets, with a prayer room available. The international patients office books accommodation for both of you, arranges the airport transfer and daily transport, and prepares the appointment confirmation and the invitation letter naming the hospital and your treating doctor for a medical visa application, around ten days before travel. Say in your first message what you need in order to be comfortable, whether that is a particular diet, a companion staying every night, prayer facilities or an interpreter present at every conversation and not only at the consultation, because all of it is far easier to arrange two weeks ahead than on the morning you arrive.

After you get home

Cross-border surgery fails most often in the handover and hardly ever in the operating room, so treat the paperwork as part of the treatment. Leave with the operation note, the pathology report, the discharge summary and a written follow-up plan, and give all four to your own doctor in the first fortnight whether or not anything is wrong. If you have a stoma, book the stoma nurse at home before you fly, because the first bag change without help is a bad time to be looking for a phone number.

Three appointments belong in the diary before you leave. A wound and general review at around two weeks. A discussion of the pathology result, whoever holds it. And, if any rectum or colon remains, a surveillance colonoscopy at whatever interval the surgeon specifies, which for a retained rectum after an ileorectal join is annual and indefinite. Your coordinator stays reachable on the same WhatsApp number afterwards, so a question about a wound, a stoma or a line in a report reaches somebody with your notes in front of them.

Colon resection FAQ

Will I need a stoma after a colectomy?

Usually not, when the operation is planned and you are well. Emergencies are different. In the randomized comparison for perforated diverticulitis, stoma-free survival at twelve months was 94.6 percent after a join and 71.7 percent after a Hartmann's, and 27 percent of those who had a join needed no stoma at any point.

Should I have surgery for recurrent diverticulitis?

It depends on how you feel between attacks. Over four years, further attacks affected 16 percent of operated patients and 92 percent of those treated conservatively, yet quality of life at four years differed by only 5.54 points with a confidence interval crossing zero. Surgery reliably stops attacks and improves daily life mainly in people whose daily life is poor.

Is a Hartmann's procedure reversible?

In principle yes, and in practice often not. Across 35,774 American patients, the stoma had been closed within a year in 53.4 percent of Hartmann's patients against 83.6 percent of those who had a join protected by a temporary ileostomy, with median times to closure of 115 days against 72.

Do I need bowel preparation before the operation?

The honest answer is that it is disputed. A randomized trial of 417 patients found wound infection in 7 percent of those prepared with laxatives and oral antibiotics against 11 percent of those given nothing, a difference within chance, and its authors said the recommendation should be reconsidered. Large observational datasets point the other way.

How will my bowels work afterwards?

It depends which segment came out. Right-sided resections cause looser and more frequent stools most often, left-sided ones usually settle close to normal, and a total colectomy joined to the rectum means several loose stools a day. If loose stools persist after a right hemicolectomy, ask about bile acid malabsorption, which was present in 82 percent of one such group.

Is keyhole surgery better for benign disease too?

On the evidence available, yes. A randomized trial of 104 patients having sigmoid resection for diverticular disease found major complications in the first six months in 9 patients against 23. Long term, five year adhesive obstruction after partial colectomy was 2.8 percent following keyhole surgery and 5.5 percent following open.

What are the options in ulcerative colitis?

A subtotal colectomy first, then either a pouch built from small bowel or a join straight to the rectum. Across 20 studies and 2,538 patients the ileorectal join had to be abandoned in 20.4 percent and cancer developed in the retained rectum in 2.4 percent, which is why annual surveillance is part of that choice.

Does exercising before surgery help?

In the one randomized trial of frail patients, it did not. Among 110 patients of average age 78, training before surgery gave no reduction in complications compared with the same training afterwards, with an adjusted mean difference of minus 3.2 and a confidence interval from minus 11.8 to 5.3.

How long should I stay in Turkey?

Twelve to sixteen days for a planned segmental colectomy, and longer for a total colectomy or if you arrive as an emergency. The number is set by the leak window, which runs from the third to the seventh day, and by the pathology report where the operation was for cancer.

What should I take home with me?

The operation note, the pathology report, the discharge summary and a written follow-up plan. Whoever looks after you at home needs to know exactly what was removed and how the join was made, and none of it can be reconstructed later from memory.

References

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Editor's note

Written by the Biruni Hospital medical editorial team. Reviewed by Prof. Dr. Cemalettin ERTEKİN, General Surgery.

Medically reviewed by

Prof. Dr. Cemalettin ERTEKİN

General Surgery

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