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Many children with familial polyposis (FAP) and ulcerative colitis (UC) can be medically managed into adulthood. However, some suffer from refractory disease, experience adverse disease sequelae (growth retardation and delayed puberty), or suffer treatment-related complications. For these patients, restorative proctocolectomy with ileal pouch–anal anastomosis provides an effective alternative to continued ineffective medical management. Variations of one-, two-, and three-stage procedures have been performed with good outcomes. The choice of staging the procedure is up to the discretion and experience of the surgeon. We generally perform a two-stage procedure for a healthy, nonimmunosuppressed patient with FAP and utilize a three-stage approach for the majority of patients with UC.
Preoperative Preparation
Mechanical and chemical bowel preparation is sometimes done the day prior to operation. Broad-spectrum antibiotics should be administered within 60 minutes of the incision, and sequential compression devices (SCDs) should be placed prior to induction. Pharmacologic deep vein thrombosis (DVT) prophylaxis is given to patients based on hospital guidelines. The patient is positioned in a modified lithotomy position using stirrups. All pressure points should be well padded to avoid pressure injuries. The arms are tucked at the patient’s side and a urinary catheter is inserted. The knees are kept in line with the torso. This allows easier mobility of the laparoscopic instruments.
Operative Technique
Colectomy
The surgeon and assistant driving the camera stand opposite the area being resected during the procedure. A second surgical assistant starts between the legs but can be moved around the patient as needed during the procedure ( Fig. 13-1 ). The site for the ileostomy is chosen in the right lower quadrant (RLQ). Incision and dissection are performed, and a SILS port (Medtronic Inc., Minneapolis, MN) is placed through this incision. The colectomy can be done as a SILS procedure or using the traditional laparoscopic approach. With the traditional laparoscopic approach, two or three 5-mm ports are utilized in addition to the RLQ SILS port, one in the left lower quadrant (LLQ), one in the suprapubic midline, and often one in the umbilicus ( Fig. 13-2 ). Colon mobilization can be started either at the rectosigmoid junction or at the cecum. This description will be of a lateral-to-medial colectomy ( Fig. 13-3 ), starting on the right side.
The patient is positioned right side up and in steep Trendelenburg. The appendix is retracted medially, exposing the lateral attachments of the colon to the lateral abdominal wall. Using electrocautery, the peritoneum is incised just medial to the white line of Toldt, allowing the right colon to be mobilized and retracted medially. It is important not to dissect too laterally since the kidney can inadvertently be retracted medially as well.
When the dissection reaches the hepatic flexure, the patient is placed in reverse Trendelenburg and the transverse colon is retracted caudally. The hepatic flexure has a more robust vascular supply and this is ligated/divided using the Enseal device (Ethicon Endosurgery, Cincinnati, OH), taking care to identify and protect the duodenum and inferior vena cava. This dissection of the hepatocolic ligament is carried across to the midline to where the gastrocolic ligament is encountered.
At this point, one can continue in the same direction, opening up the lesser sac, keeping the dissection plane close to the colon. Alternatively, the surgeon can switch to the patient’s left side to start at the splenic flexure and work back medially. With this approach, the patient is placed left side up and in reverse Trendelenburg, and the colonic attachments to the spleen are taken down with the Enseal. The lesser sac is then entered and the dissection is carried medially to join the previous dissection. The omentum is left attached to the colon.
The lateral peritoneal attachments to the left colon are then incised with an electrocautery device down to the sigmoid attachments, and both ureters are identified and protected. Once these attachments are freed, the upper rectum is identified and a mesenteric window is created with the cautery, taking care not to injure any pelvic structures. If a three-stage procedure is being done, the rectum is stapled and a nonabsorbable suture is placed for aid in future identification of this rectal stump.
Attention is then turned medially and the mesentery to the entire colon is ligated/divided with the Enseal. This is performed by lifting the colon and positioning it in a cranial-caudal orientation. The dissection plane should be close to the colon. The right mesocolon is divided as close to the colon as possible to save the right colic artery and marginal artery branches, which often serve as the main blood supply to the terminal ileum and the J-pouch. Care is also taken to avoid injuring the ileocolic artery for the same reason. Dissection is carried to the cecum and the entire colon can then be eviscerated via the SILS port/ileostomy site. The attachments to the terminal ileum can be taken down extracorporeally and the ileum stapled. The resected specimen is then removed.
If a two- or three-stage procedure is being performed, the pneumoperitoneum is re-established to evaluate for hemostasis, and the cannulas are removed and the incisions closed. The ileum is confirmed not to be twisted and is exteriorized through the RLQ incision, and a Brooke ileostomy is created.
Restorative Proctectomy with J-Pouch–Anal Anastomosis with or without Protecting Loop Ileostomy
Six weeks after the laparoscopic colectomy, the second stage is performed. The patient is placed in the same position as for the colectomy and the rectum is irrigated to remove any residual stool or purulence. The ileostomy is taken down from the skin and fascia, and mobilized to the level of the peritoneum. The distal ileum is then eviscerated and evaluated to see if it will reach the pubic tubercle. If the ileum reaches the pubic tubercle extracorporeally, the J-pouch should reach the distal rectum/perianal area internally. If the ileum does not reach, additional length can be gained by incising the peritoneum of the mesentery both anteriorly and posteriorly, which usually gains several centimeters of additional length ( Fig. 13-4 ). Lysing the filmy attachments to the duodenum can also give additional length to the ileum.
