The location and number of ports used for laparoscopic rectal surgery in IBD varies considerably between colorectal surgeons. There are multiple variations and configurations that can be used; most surgeons at our institution gain access via a cut down technique and place a 10-mm port in the supraumbilical position. After gaining adequate pneumoperitoneum (between 12 and 14 mmHg), a generalized exploration is undertaken of the abdominal and pelvic cavities; additional ports can then be placed under direct visualization. Most often, a left sided 5-mm port is placed along with a right lower quadrant 5- or 12-mm port. Additionally, a suprapubic port of either 5- or 12-mm is placed as well. Depending on the planned extraction site and how the rectum is transected will dictate the exact number, location, and size of the ports. Additionally, some surgeons in our department will use the planned ileostomy site as a port and as the extraction site. Furthermore, if a single-port device is utilized for the rectal dissection, it can similarly be placed at the planned ileostomy site (see video).

The laparoscopic abdominal colectomy portion of the procedure has been described previously from our unit. When a laparoscopic STC and EI is performed for acute colitis in a 3-stage procedure for UC, the authors routinely implant the rectosigmoid stump above the fascia at the extraction site which is via a small Pfannenstiel or lower midline incision, due to the friable nature of the tissues. We prefer a controlled wound infection rather than a rectal stump “blowout” in the pelvis, which will undoubtedly make the future proctectomy more difficult and technically challenging, especially laparoscopically. In terms of colon mobilization, the authors prefer a medial-to-lateral approach, working sequentially from the right to left side. Most often, vascular division is performed with tissue sealing devices and are only performed in a high ligation fashion if there has been biopsy-proven carcinoma or dysplasia with or without a dysplasia-associated lesion or mass (DALM).

Either performed as part of a TPC or as the second stage as a completion proctectomy, rectal dissection is essentially done the same way. If a STC and EI have been performed previously, the long rectosigmoid stump (if implanted above the facial level) is identified in the subcutaneous tissues at the previous extraction site and is dissected free and then placed inside the abdominal cavity. In cases where the stapled off rectal stump has been left in the pelvis, the surgeon can use the same laparoscopic ports from the previous abdominal colectomy to perform the operation.

Whether performing a CP or the initial TPC, dissection at the sacral promontory is achieved by scoring the mesentery cephalad to the inferior mesenteric artery, which is then ligated (after proper identification of the left ureter) with a tissue sealing device; it is not mandatory to perform a high ligation of this vessel, unless carcinoma or dysplasia has been established (Fig. 9.2). Complete mobilization to the pelvic floor is accomplished with the use of tissue sealing devices or alternatively can be accomplished with electrocautery or scissor dissection, which many believe can provide a more “accurate” dissection. A nerve-sparing compete mesorectal dissection is undertaken (Fig. 9.3). Laterally, the left pararectal peritoneum is scored followed by medial dissection to the sacral promontory. At the sacral promontory, identification of the hypogastric nerves is accomplished and these are spared; often if the loose areolar tissue at the sacral promontory is dissected too close to the bone, one can actually get behind the nerves and cause damage. Laterally on the right, the right ureter is identified and the peritoneum is scored. We tailor the mesorectal excision so that the lateral dissection is performed closer to the rectal wall than to the pelvic sidewalls to minimize the risk of nerve injury at this level. The dissection continues posteriorly and laterally to the pelvic floor.

Once posterior and bilateral mobilization is complete, attention is turned anteriorly, which usually is the most challenging portion of the operation. In the male patient, care is taken to protect the seminal vesicles and the prostate and in the female patient, the dissection of the rectovaginal septum off the rectum may prove difficult. Occasionally, insertion of a sponge stick (or other instrument) is inserted into the vagina to help facilitate dissection of this plane. Unless the patient has carcinoma or dysplasia anteriorly in the rectum, Denonvillier’s fascia is preserved.

An appropriately completed rectal dissection to the level of the pelvic floor (levators) should expose the distal rectum as a tubular structure not covered by fat or mesorectum at the level of the anorectal ring. At this time, as in an open approach, digital rectal exam with the index finger is performed to confirm the appropriate level of dissection has been reached. Often the proximal interphalangeal joint at the level of the anal verge provides a useful estimate of the appropriate level of transection (Fig. 9.4). The vast majority of IPAA performed at our institution entail a stapled anastomosis at the top of the anal canal, thereby preserving the anal transition zone, unless there is rectal cancer or dysplasia of the rectum—in this scenario, a mucosectomy with hand-sewn anastomosis is preferable.