Shah's Gastro, Cancer & Robotic Surgery Centre · Ahmedabad & Gandhinagar
The bag is the part most people dread, and the part least often explained. Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad.
A cancer in the middle third of the rectum is removed by an anterior resection: the rectum carrying the tumour is taken out with the whole envelope of fat and lymph nodes around it, and the colon above is joined to the rectal stump below. Because that join sits deep in the pelvis, many patients also receive a temporary ileostomy — a loop of small bowel brought out on the abdominal wall for a few months. It does not stop the join leaking. It diverts stool away from it, so a leak can be managed with antibiotics and a drain instead of an emergency operation. It is closed at a second, much smaller operation once adjuvant treatment is finished and a contrast study confirms the join has healed.
Shah’s Gastro, Cancer & Robotic Surgery Centre. Rectal cancer surgery is not general surgery with a longer incision. The dissection runs in a plane a few millimetres wide, between the envelope carrying the tumour’s lymph nodes and the nerves that control the bladder and sexual function — nerves that are found and preserved deliberately, not avoided by luck. Dr Harsh Shah’s training is in surgical gastroenterology as a super-speciality — MS, then MCh and DrNB — and rectal resection with total mesorectal excision, open, laparoscopic and robotic, is core work rather than occasional work.
The same surgeon who counsels you in the clinic performs the operation and reviews you afterwards, including at the visit where the ileostomy closure is planned.
The rectum is roughly the last fifteen centimetres of the large bowel, and surgeons divide it into thirds only because each third behaves differently on the operating table. The middle third sits below the peritoneal reflection and above the muscles that hold continence. A tumour here is far enough from the anus that the sphincter can usually be kept, and far enough from the abdominal cavity that the operation is done deep in the bony pelvis rather than in open space.
That geography is the whole story. The lower the tumour, the lower the join, and the lower the join, the more likely it is to be protected by a temporary ileostomy. It is why the first honest answer to “will I need a bag?” is that the MRI has to be read first.
A tumour in the upper third is often treated with a partial mesorectal excision. One in the middle third, particularly its lower part, usually requires the whole mesorectum to be taken to the pelvic floor — which puts the join deeper and changes the discussion about diversion. The wider picture is on the rectal cancer treatment page.
Rectal cancer is an MRI-driven disease. No decision about the operation, about radiotherapy, or about a stoma should be made before a proper pelvic MRI has been reported.
The scan is asked to answer specific questions, and a report that does not answer them is sent back rather than worked around. How deeply the tumour has grown through the bowel wall. How close it comes to the mesorectal fascia — the outer skin of the envelope that will be removed — because a tumour touching that line changes the plan completely. Whether tumour is growing inside the draining veins. Which lymph nodes look involved. And the height of the lower edge of the tumour from the anal verge.
Alongside the MRI: a colonoscopy with biopsy that has reached the caecum, so a second tumour further up is not discovered after the operation has been planned; a CT of the chest, abdomen and pelvis; a baseline CEA; and an assessment of nutrition, diabetes control and fitness for anaesthesia. Every case is then discussed in a multidisciplinary meeting before treatment begins — stricter than for colon cancer, because the sequence of treatment is decided in that room.
One more step belongs here rather than on the morning of surgery. If a stoma is a realistic possibility, the site is marked on the abdominal wall by the stoma nurse beforehand, with the patient sitting, standing and lying down. A stoma placed in a skin crease or under a waistband is a preventable misery.
The oncological constant in rectal cancer surgery is total mesorectal excision. The rectum and the fatty envelope around it are separated from the pelvic side wall by sharp dissection in a natural, almost bloodless plane, and lifted out as one intact package. The quality of that package — a smooth, unbreached envelope, a clear margin all the way round, an adequate length of bowel below the tumour — is what the pathologist grades, and it predicts more about the future than almost anything else the surgeon does.
The approach may be open, laparoscopic or robotic. The robotic platform has a real ergonomic advantage deep in a narrow male pelvis, where wristed instruments and a stable camera make the lowest part of the dissection more controlled. But the endpoint is the specimen, not the size of the incision, and the correct decision when the plane is being lost is to convert to open surgery without hesitation. Where radiotherapy has been given first, the operation is timed some weeks after it finishes, because operating into an acutely irradiated pelvis makes both the join and the wounds less reliable.
At the end, the colon is joined to the rectal remnant. The join is tested on the table — with air, or by passing a flexible scope to look at it directly — and a pelvic drain is usually left, which is standard after a low join even though it is not standard after a colon resection.
A defunctioning ileostomy does not prevent a leak. It converts a catastrophic leak into a manageable one. That single sentence is the entire justification, and it is the sentence patients are most often not given.
A join deep in the pelvis is the most demanding anastomosis in abdominal surgery. It sits low, it has a less generous blood supply than a join higher up, and it may have been irradiated. If such a join leaks with stool passing over it, the pelvis is contaminated and the patient is usually looking at an emergency operation and a permanent stoma. If it leaks with a loop of ileum diverting stool away, the same event is often managed with antibiotics and a drain while the join heals underneath.
So the ileostomy is not made because the surgeon lacks confidence in the join. It is made because of what a leak would cost if one occurred. The factors pushing towards diversion are those that make a leak likelier or more dangerous: a join very low in the pelvis, radiotherapy beforehand, a narrow male pelvis, poor nutrition, diabetes, steroids, smoking, emergency surgery. A middle-third tumour whose join ends up high, in a well-nourished patient who has not had radiotherapy, may reasonably be done without one.
The honest position is that this is a judgement made with the abdomen open, informed by everything above, and discussed with you beforehand as a likelihood rather than as a promise. Anyone who settles the question before seeing the pelvis is settling it on incomplete information.
What it actually is: a loop of small bowel brought through the abdominal wall at the marked site, opened and stitched to the skin, so stool leaves into a bag before it ever reaches the join. The bowel is not divided — which is precisely what makes closing it later a modest operation. Output is looser and more frequent than stool from the back passage, and needs fluid and salt attention rather than alarm.
Recovery in hospital is then shaped by the bag rather than by the abdomen. The catheter comes out early, diet restarts quickly, walking starts on the first day, and the drain comes out once it is clear. What actually determines the discharge date is stoma independence — whether the patient or a family member can change the appliance unaided. Teaching starts the day after surgery for that reason.
Closure is planned once two conditions are met, and not before either. The first is that adjuvant chemotherapy, if recommended, has finished. The second is that a contrast study has looked at the join and shown it intact, with no leak and no narrowing. In practice that places closure a few months after the first operation, timed by the treatment in between rather than by the calendar.
The operation itself is small by comparison: an incision around the stoma, the loop freed and the opening closed or a short segment removed and re-joined, and the abdominal wall repaired. Usually a short admission — but a real operation, with its own risks of wound infection, slow return of bowel function and, less often, obstruction from adhesions.
Two things must be said plainly before the first operation, because they are the part that is most often softened. Not every temporary ileostomy is closed. If the join has leaked and healed badly, if it has narrowed, if the disease has come back, or if the patient’s general condition will not support a second operation, the stoma stays. A proportion of “temporary” stomas become permanent, and anyone consenting to a defunctioning ileostomy is entitled to hear that at the outset rather than to discover it later.
The second is what bowel function is like after closure. Once stool passes through a rectum that is shorter and less elastic than it was, many people experience urgency, frequency, going several times in a cluster and then not at all, difficulty telling wind from stool, and sometimes leakage. This has a name — low anterior resection syndrome — and it is expected rather than a sign something has gone wrong. It generally improves over one to two years and responds to bowel retraining, loperamide, pelvic floor physiotherapy and, in stubborn cases, transanal irrigation. It belongs in the conversation before consent, not afterwards.
A surgeon who welcomes these questions is the one to go with. If any answer is a number, ask whether it is a published average or a figure from this team, and ask what it means for you specifically — individual risk is always discussed in person, not quoted on a website.
★★★★★
“We came from Mp Indore for the treatment of Rectal cancer and Robotic surgery was done by Dr harsh shah....After surgery my son is good now. Heartly thankful to you sir...”
— Parasram Solanki, Google review
★★★★★
“We came from Udaipur, Rajasthan for my husband's rectal cancer surgery. Dr. Harsh Shah performed the operation with great expertise and care. He explained everything clearly and supported us throughout the treatment. The surgery was successful, and we are very grateful for the excellent care we received. Dr. Harsh Shah is one of the best rectal cancer surgeons. Highly recommended!”
— Bhupendar Dave, Google review
★★★★★
“I would like thanks Dr harsh shah operated my wife for rectal cancer . We discharged today. And she is good now. Thank u so much sir for everything. Best GI and Rectal cancer surgeon in ahmedabad.”
— Bajrang Singh, Google review
Reviews are reproduced exactly as written on Google, including the original spelling and spacing.
The specimen goes to the pathologist, and the report that comes back is the most important document of the whole illness. It describes how complete the mesorectal envelope was, whether the circumferential margin is clear, how far the tumour had grown, how many lymph nodes were examined and how many contained tumour, and whether tumour was in the veins. Where radiotherapy was given first, it also describes how much of the tumour responded.
That report is reviewed with you at about two weeks, together with the wound check, the stoma review and a dietitian if needed. It decides whether chemotherapy is recommended after surgery, and it sets the timetable for everything that follows.
Surveillance is then structured rather than occasional: symptom review, examination, weight and a CEA blood test every few months for the first years, scans at set intervals, and a colonoscopy on schedule. After closure, bowel, sexual and urinary function are asked about at every visit, because patients very often do not volunteer them.
Anterior resection for rectal cancer is covered by most health insurance policies and by CGHS, and the admission is planned rather than sudden, so the paperwork can be done properly in advance. The office prepares the pre-authorisation and follows it through with the insurer.
The closure of the ileostomy is a separate admission and a separate claim, and it is worth asking your insurer about it at the time of the first operation rather than months later. Policies differ on how a planned second procedure within the same illness is treated, and finding out early avoids an unpleasant surprise.
What changes the final figure is the approach used, the length of stay, whether radiotherapy preceded surgery, and the room category chosen. A written estimate is given before admission.
Not necessarily. For a middle-third tumour it depends on how low the join ends up, whether radiotherapy was given first, and your general condition. It is discussed with you as a likelihood before surgery and decided finally in theatre.
A defunctioning ileostomy is intended to be temporary and is closed at a second operation. It is honest to say that not every one is closed — if the join healed badly, narrowed, or the situation changed, it may stay.
Usually a few months. The timing is set by whether chemotherapy is needed after surgery and by the contrast study confirming the join has healed, not by a fixed date.
Yes, particularly before a decision about radiotherapy or about a stoma. A proper second opinion needs the MRI images themselves, not just the report.
Shah’s Gastro, Cancer & Robotic Surgery Centre — Gota, Ahmedabad
Consultations, review of colonoscopy, biopsy and MRI reports, second opinions, stoma and surveillance follow-up.
Google: Dr Harsh Shah · 4.89 from 216 reviews
Directions to the Gota clinic
Apollo Hospital — Bhat, Gandhinagar
Admission, surgery and inpatient care, including ileostomy closure.
Google: Dr Harsh Shah – Robotic GI Surgeon · 4.94 from 17 reviews
Directions to Apollo, Bhat
Patients travel here for rectal cancer surgery from across Gujarat, Rajasthan and Madhya Pradesh. If you are coming from out of state, send the reports ahead so the first visit can be a decision rather than an introduction.
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