Restorative Proctocolectomy: Laparoscopic Proctocolectomy and Ileal Pouch-Anal Anastomosis

Tonia M. Young-Fadok

Definitions

Extent of Operation

To avoid confusion regarding naming conventions, this chapter will employ the following terms. Total colectomy describes resection of the entire colon, with either an ileorectal anastomosis (IRA) if bowel continuity is preserved, or Brooke ileostomy and retention of the rectal stump. Proctocolectomy refers to surgical removal of the entire colon and the rectum. The word “total” as sometimes used in “total proctocolectomy” is thus redundant and not used in this chapter.

Following proctocolectomy, the terminal ileum is either matured as a Brooke ileostomy, or, more commonly, is used for a reconstructive procedure to reestablish bowel continuity, in the form of an ileal pouch, which is anastomosed to the anal canal. Infrequently, it may be used for a continent ileostomy. Reconstruction with an ileal pouch is referred to by two common terms, restorative proctocolectomy (favored by the British and Cleveland Clinic) and proctocolectomy and ileal pouch-anal anastomosis (IPAA), a term more commonly used by Mayo Clinic. I prefer the latter description as it describes the means of restoration of bowel continuity.

Laparoscopic Procedures

Naming conventions for laparoscopic procedures, especially in the field of colorectal surgery, are somewhat open to interpretation. Most surgeons would agree on the following usages. A procedure is laparoscopic if the procedure is laparoscopically completed and the main incision is used only for extraction of the specimen. Laparoscopic-assisted usually means that a portion of the case was performed extracorporeally,
such as anastomosis in a right colectomy (although if the incision is the same as used to extract the specimen, this differentiation is splitting hairs). In a hand-assisted procedure, a 6–8-cm incision is used to place a device that allows a hand to be inserted into the abdominal cavity to facilitate the procedure. This incision is larger than the typical 3–5-cm incision used for extraction of the specimen. In a hybrid procedure, a portion of the case is laparoscopically performed, such as mobilization of the abdominal colon, and then a small incision (infraumbilical midline or Pfannenstiel) is used to facilitate dissection of the rectum or deployment of a stapler. The hand-assist-incision may be used for this type of procedure, and thus many purists consider hand-assisted and hybrid cases to be similar in terms of incision length.

With regard to laparoscopic proctocolectomy and IPAA, a laparoscopic-assisted procedure would generally enlarge a supraumbilical port site incision, by extending it around the umbilicus to a 3-5-cm periumbilical extraction incision and then create the ileal pouch through this incision. In this chapter, a completely laparoscopic proctocolectomy and IPAA involves complete laparoscopic mobilization of the colon and the rectum, transection of the rectum and mesentery intracorporeally, and extraction of the specimen via the planned ileostomy site so that no port site is enlarged and no additional incision is employed for specimen extraction. The pouch is still constructed extracorporeally, but the ileostomy site incision is not enlarged to accomplish this goal. I prefer “completely” laparoscopic to “totally” laparoscopic given the confusion with naming conventions and the extent of procedure as noted above when the word “total” is used.

Indications/Contraindications

The two most common pathologic diagnoses for which IPAA is undertaken are ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Infrequently, the procedure may be appropriate in an individual with hereditary nonpolyposis colorectal cancer (HNPCC) with a rectal neoplasm, as distinct from the more common right-sided lesions that prompt a total colectomy and IRA.

The reasons for recommending IPAA in patients with UC are: disease refractory to medical therapy; complications of medications used to treat the disease; inability to wean steroids despite responsiveness of the disease; failure to thrive in pediatric patients; and patient preference in the case of those patients who prefer an operation to long-term medication. Surgeons consider IPAA to be the appropriate recommendation in patients with FAP. Others will consider total colectomy and IRA if there is relative rectal-sparing with few rectal polyps. This author’s preference is for IPAA in all cases of FAP, but to consider IRA in patients with attenuated FAP with rectal sparing.

The discussion of contraindications will distinguish between contraindications to IPAA, to laparoscopic IPAA (L-IPAA), and completely laparoscopic IPAA (CL-IPAA). In the patient with UC, IPAA may not be appropriate in an emergency situation, such as perforation, toxic megacolon, and hemorrhage. This decision will depend on whether the patient is hemodynamically stable, the duration of their symptoms, and the expertise of the surgeon. Consideration must be given to stabilization of the patient and whether or not a total colectomy and Brooke ileostomy (TC&B) may be the safest and most expeditious approach. Procedures performed may range from open total colectomy and Brooke ileostomy (TC&B) in the unstable patient with perforation, to L-IPAA in the stable patient with bleeding but no evidence of malnutrition. Malnutrition (low albumin, low pre-albumin, World Health Organization definition of >10% weight loss) should prompt TC&B rather than IPAA. Emerging data suggest that recent administration of biologic medications may increase the risk of pouch complications. Thus, I will not perform IPAA in patients within 8 weeks of receiving Infliximab or 2 weeks of Adalimumab, but instead recommend a three-stage procedure. Only one additional contraindication applies to CL-IPAA—obesity. In the obese patient, the resected colorectum cannot be extracted via the ileostomy site without enlarging the incision. Although the enlarged fascial incision can be made smaller with sutures, the skin incision cannot and maturation of the stoma results in deformity that contributes to difficulty with looking after the stoma.

Preoperative Planning

For all patients undergoing elective surgery, a formal preoperative assessment consists of the following steps: evaluation in our preoperative clinic by a trained clinician to exclude issues pertaining to anesthesia; basic blood tests including electrolytes, complete blood count, and albumin and pre-albumin when indicated by history; chest x-ray and EKG when appropriate; type and screen within 72 hours of operation; and pregnancy test when applicable. All patients consult with our stoma nurses to mark the most appropriate site for the planned ileostomy. Some data suggest that bowel preparation is unnecessary, but these data are from open cases. Laparoscopic handling of the bowel requires a bowel preparation, and this “completely laparoscopic” approach demands it! The vast majority of patients undergoing this operation have had prior colonoscopies and can suggest which preparation has worked best for them and been tolerated. This author has no specific preference regarding bowel preparation.

On the day of operation, patients who have had a prolonged course of steroids within the preceding 6–12 months, but are now off steroids, receive a dose of methylprednisolone 20 mg intravenously on call to the operating room and then a rapid taper over 3 days. Patients who are currently taking prednisone receive a 10–20 mg higher dose of methylprednisolone (on a mg/mg basis) and then are tapered over 3 days to the preoperative dose.

NSQIP guidelines are followed; in patients who do not have a penicillin allergy, ertapenem 1 g i.v. is administered within 60 minutes of the incision with no postoperative doses required. The penicillin-allergic patient receives metronidazole 500 mg i.v. and ciprofloxacin 400 mg i.v. within 60 minutes of the incision. All patients are preoperatively given a warming blanket as this contributes to the maintenance of postoperative normothermia.

Surgery

Positioning

Success of the operation begins with correct positioning. Three key points govern positioning: (a) steep gravity changes are used, so the patient must be safely secured to the table; (b) there must be access to the perineum for stapled or sutured anastomosis; and (c) the position must facilitate the laparoscopic approach. Thus, the patient is placed in a modified combined synchronous position (modified lithotomy). We use medical grade pink egg-crate foam to ensure that the patient does not slip or slide. This egg crate is taped to the bed over a drawer sheet placed beneath the foam to be used for tucking the arms. The legs are placed in padded Allen stirrups and positioned with the thighs within 5 degrees of being parallel with the abdominal wall so that instruments used in the lower trocars during dissection in the upper abdomen are not hampered by the thighs. The hands are wrapped in foam and tucked adjacent to the torso. A commercial warming device is placed over the chest, followed by a folded blanket (to prevent tearing of the Bair Hugger, so it may be used in the recovery room), and linen tape is wrapped around the patient’s chest and around the table three times. A “tilt test” is then performed: the OR table is then moved into all the potential extreme positions used during the case to ensure that the patient is safely affixed to the table.

A bladder catheter is placed and an orogastric tube is inserted to be removed at the end of the procedure.

Surgical Technique

Rationale

A lateral-to-medial approach is utilized for several reasons. First, the approach is similar to the open approach and trainees more readily recognize the anatomic landmarks.

Only gold members can continue reading. Log In or Register to continue