Restorative Proctocolectomy—Hand Assisted
Peter W. Marcello
INDICATIONS/CONTRAINDICATIONS
Restorative proctocolectomy is the procedure of choice for patients with ulcerative colitis, requiring surgical intervention, who wish to have a restorative procedure. The procedure is also indicated in patients with familial adenomatous polyposis with extensive rectal polyp formation. Unless otherwise contraindicated, a laparoscopic approach is preferred. Whether the procedure is performed by multiport laparoscopy or hand-assisted surgery is based on the surgeon’s experience. A hand-assisted approach compared to a laparoscopic approach has been associated with a reduction in operative time and conversions, and therefore is the author’s preferred approach. There are rare contraindications, such as the following:
Extensive adhesion formation from prior surgery
Inability to tolerate pneumoperitoneum
PREOPERATIVE PLANNING
There are no specific preoperative planning needs for a hand-assisted approach compared to either laparoscopically or conventional open surgery. Appropriate preoperative antibiotics, heparin administration, and marking of a site for temporary fecal diversion, should be planned.
SURGERY
Positioning
The patient is placed in a modified lithotomy position on a spilt-leg electric table.
The arms are at the sides surrounded by a beanbag.
Three-inch silk tape is wrapped around the patient and beanbag to the table.
Technique
The operation begins with partial creation of the ileostomy (Fig. 27-1).
A core of skin and subcutaneous tissue is removed.
The anterior rectus sheath is vertically incised.
This step is done to prevent the development of an obstruction of the loop ileostomy by the anterior rectus sheath following closure of the fascia in the Pfannenstiel incision. When a Pfannenstiel incision is created, the anterior rectus sheath is dissected from the rectus muscle and will fold upward. If the ileostomy is made after the Pfannenstiel incision is created, it can act as a “shutter valve” when the fascia is closed, and may cause an obstruction at the ileostomy. This obviously is only done in cases where a temporary loop ileostomy is planned.
An 8-cm Pfannenstiel incision is made two fingerbreadths above the pubic symphysis.
The anterior rectus sheath is incised transversely and superior and inferior flaps are created over the rectus muscles.
The peritoneum is vertically opened between the rectus muscles.
FIGURE 27-1 Trocar and incision placement.
The sleeve is placed for the hand device.
Five-mm trocars are positioned in the left lateral, umbilical, and right lateral positions. The right lateral trocar is placed lateral to, and above the ileostomy siting. Trocars are placed with the hand inside the abdomen to protect the intestine from injury (Fig. 27-1).
Right Colectomy—Medial Approach
The surgeon stands to the patient’s left with the left hand through the hand port and the right hand with a laparoscopic instrument (Fig. 27-2). The assistant stands cephalad to the surgeon, holding the camera. The patient is in slight Trendelenburg position with the right side up.
An exploration is undertaken; the colon is examined to determine the extent and severity of disease and the small bowel is examined to exclude Crohn’s disease.
The cecum and terminal ileum are elevated and laterally retracted with the hand.
A medial-to-lateral dissection of the right and transverse mesocolon is performed. An incision is made under the ileocolic pedicle and the duodenum is swept downward (Fig. 27-3). The ileocolic pedicle is then isolated. The fingers are quite useful for isolating the pedicles. The ileocolic vessels are then divided and ligated using a bipolar vessel-sealing device (Fig. 27-4). The 5-mm bipolar sealing device is the preferred method of vessel ligation and division. Multiple applications of the device are used before the pedicle is divided. Although somewhat controversial, the author’s preference is to divide the ileocolic vessels.
The right-sided colon is mobilized from medial to lateral (Fig. 27-5). The colon mesentery is freed from the retroperitoneum and duodenum. A hand is used to create traction while the scissors are used to perform the dissection.
If present, the right colic vessels are isolated and divided.
Transverse Colectomy—Medial Approach
Attention is then shifted to the transverse mesocolon. The assistant moves from the patient’s left side to stand between the legs. The assistant’s left hand elevates the transverse mesocolon with a laparoscopic instrument through the right lateral trocar. The assistant’s right hand controls the camera
through the umbilical port. The surgeon remains to the patient’s left side, with the left hand through the hand device and the right hand with a laparoscopic instrument. The assistant elevates the transverse mesocolon with a grasper in the left hand through the right-sided trocar, while the surgeon isolates each of the individual middle colic vessels. The dissection generally begins to the left of the midline in the transverse mesocolon (Fig. 27-6). This plane often has fewer adhesions into the lesser sac. The lesser sac is entered and the distal transverse mesocolon sharply divided.
through the umbilical port. The surgeon remains to the patient’s left side, with the left hand through the hand device and the right hand with a laparoscopic instrument. The assistant elevates the transverse mesocolon with a grasper in the left hand through the right-sided trocar, while the surgeon isolates each of the individual middle colic vessels. The dissection generally begins to the left of the midline in the transverse mesocolon (Fig. 27-6). This plane often has fewer adhesions into the lesser sac. The lesser sac is entered and the distal transverse mesocolon sharply divided.
 FIGURE 27-2 Surgeon and assistant positioning. |
 FIGURE 27-3 Isolation of ileocolic pedicle. |
 FIGURE 27-4 Ligation of ileocolic pedicle with bipolar energy. |
 FIGURE 27-5 Medial to lateral mobilization over duodenum and Gerota’s fascia. |
 FIGURE 27-6 Isolation of the middle colic vessels. |
Working back toward the patient’s right side, the main trunk middle colic vessel is isolated and divided (Figs. 27-7 and 27-8). The middle colic vessels may sometimes be ligated together or individually. Excessive tension on the vessels should be avoided when using a bipolar vessel-sealing device. The entire proximal and mid-transverse mesocolon has now been fully divided.
 FIGURE 27-7 Ligation of middle colic pedicle. |
 FIGURE 27-8 Isolation of the right branch of the middle colic vessels. |
Right and Transverse Colectomy—Lateral Approach
The terminal ileum and right colon are laterally mobilized. This portion begins by a laparoscopic technique.
Scissors are placed directly through the hand device and a grasper through the left lateral trocar. The cecum and terminal ileum are mobilized.
The hand is then used to help mobilize the terminal ileal mesentery up to and then over the duodenum as a critical lengthening maneuver when performing ileoanal pouch construction.
The remaining lateral attachments are divided, with the assistant using the hook cautery through the right lateral trocar, and the surgeon remaining in the same position with the left hand in and the right hand with a laparoscopic grasper.
The bipolar vessel sealer may also be used to help separate the omentum, and control any minor bleeding (Figs. 27-9 and 27-10). After the right and transverse colon have been mobilized and devascularized, they are placed back into anatomic position before turning to the left colectomy.Related posts:
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