Keyhole surgery for cancers in the abdomen

What happens, step by step

1. 1
   The decision, taken before the day of surgery.

   Whether your operation is keyhole or open is settled in the clinic, not in theatre. Your surgeon reads the scans and the pathology report, asks what abdominal operations or caesareans you have had before, and tells you which way it is planned. Your case has already been through the tumour board, so it is a plan several doctors agreed on. You are also told here that an operation begun as keyhole is occasionally completed as an open one — easier to hear now than afterwards.

2. 2
   The check-up before the anaesthetic.

   A few days before, you see the anaesthetist. Blood tests, an ECG and usually a chest X-ray are done, and your heart, lungs, sugar and blood pressure are checked, because the anaesthetic has to be safe for the body it is given to. Bring every medicine you take, in its own packet: blood thinners, some diabetes medicines and some herbal preparations have to be stopped or changed, and you are told which and from when. If you smoke, stopping now makes a chest infection afterwards less likely.

3. 3
   The night before, and the morning of.

   You are usually admitted the day before, asked not to eat after a stated time — commonly midnight — and not to drink after a later one. Take your morning medicines only if you have been told to. Some bowel operations need a preparation to empty the bowel, and that evening is the uncomfortable part rather than the operation. The consent form is gone through with you: what is planned, what will be removed, what could change. One person from the family should stay, and should know where to wait.

4. 4
   The anaesthetic.

   You are taken to theatre on a trolley. The room is cold and bright and there are more people in it than you expect; that is normal. A cannula goes into the back of your hand, monitors go on your chest and finger, and you breathe oxygen through a mask while the anaesthetic goes in. You are asleep within a minute, you will not feel the operation and you will not remember it. A breathing tube is placed after you are asleep, which is why the throat is often sore that evening.

5. 5
   The operation itself.

   Carbon dioxide gas is let into the abdomen to lift the wall away from the organs and make room to work. Three to five small cuts are made, each about the width of a fingernail; the camera goes through one and the instruments through the others. Your surgeon works from the screen, which sits closer to the tissue than the eye could. The tumour, the part of the organ around it and the lymph nodes nearby are freed and taken out, usually through one opening widened a little. The cuts are closed with stitches under the skin, and a soft drain is sometimes left for a day or two.

6. 6
   If the operation is completed as an open one.

   This happens sometimes, and it is a judgement rather than a complication. Scar tissue from an earlier operation may have stuck the organs together, the tumour may be larger or more fixed than the scans showed, or the view may not be good enough to work safely. Your surgeon then changes to a longer cut and finishes the operation that way, because finishing it properly matters more than finishing it through small cuts. You and your family are told afterwards what was found and why it changed. It does not mean the first plan was wrong.

7. 7
   Waking up, and the first day.

   You wake in the recovery area with oxygen on your face and a nurse beside you, and go to the ward once you are awake enough. Expect a sore throat, a dry mouth and pain at the small cuts. The one that surprises people is pain at the tip of the shoulder: that is gas left under the diaphragm irritating a nerve, it has nothing to do with your shoulder, and it settles over a day or two. You will be asked to sip water, to breathe deeply into a small device, and to sit out of bed and take a few steps that evening or the next morning. Being got up early keeps the chest clear and the blood moving.

8. 8
   The ward, and going home.

   Over the next days the drip comes down, the catheter comes out, and you move from sips to liquids to soft food as the bowel wakes up; passing wind is the sign everybody waits for. You go home when you are eating, walking, passing urine and comfortable on tablets rather than injections, and two to four days is what is usually planned for. What was removed goes to the laboratory, and that report — 24 to 48 hours — says whether anything further, such as chemotherapy, is advised. It is discussed with you at the follow-up, not read out over the phone.

Side effects, and the support that comes with them

Expect soreness at each small cut for a week or two, worse when you cough, laugh or get out of bed — holding a folded towel against the abdomen when you cough helps more than it sounds like it should. Bruising around the openings is common. The shoulder-tip pain from the gas is the one nobody warns people about; it is neither a heart problem nor a shoulder problem, and it goes as the gas is absorbed. Bloating and wind are usual for the first days, and the first passing of wind is a good sign rather than an embarrassing one. Nausea after an anaesthetic is common and there is medicine for it, so ask rather than lying still and hoping. Strong painkillers slow the bowel, so constipation is expected and is treated with a laxative rather than endured. Appetite takes a while to return, and small frequent meals go down better than three large ones. Scars are small but permanent, and the skin around them may feel numb for months. Every abdominal operation carries some risk of bleeding, of infection in a wound, of a chest infection, of clots in the legs, and, where the bowel has been joined, of that join leaking. These are not common. They are the reason you are got out of bed early, given breathing exercises, given stockings or blood-thinning injections, and watched for a few days before you go home. Later, a bulge at one of the cut sites — a hernia — can appear months afterwards, which is why the lifting restriction is given a number and meant.

Questions we hear every week