Restorative Proctocolectomy: Laparoscopic Proctocolectomy and Ileal Pouch-Anal Anastomosis

Piyush Aggarwal

Tonia Young-Fadok

DEFINITIONS

Extent of Operation

In order to clarify regarding naming conventions, this chapter will use 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, used for a reconstructive procedure to reestablish bowel continuity, in the form of an ileal pouch, which is anastomosed to the anal canal. Increasingly infrequently, it may be used for a continent ileostomy (Kock pouch). Reconstruction with an ileal pouch is referred to by two common terms, restorative proctocolectomy and proctocolectomy and ileal pouch-anal anastomosis (IPAA). We prefer the latter because 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 procedure was extracorporeally performed, 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 laparoscopic (-assisted) operation. In a hybrid procedure, a portion of the procedure 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 procedures to be similar in terms of incision length.

With regard to laparoscopic proctocolectomy and IPAA, a laparoscopic-assisted procedure would generally enlarge a supra- or infraumbilical port-site incision, by extending it 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 either via the planned ileostomy site or via the anus, so that no port site is enlarged and no additional incision is used for specimen extraction. The pouch is still extracorporeally constructed, but the ileostomy site incision is not enlarged to accomplish this goal. We 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 seen in HNPCC, which usually prompt a total colectomy and IRA.

The indications for 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 and surveillance. Some patients with UC have indications for a three-stage procedure, including toxic megacolon, hemorrhage, malnutrition, obesity, and operating within the effective period of an antitumor necrosis factor (anti-TNF) medication. They may ultimately be candidates for a J-pouch, but not at the initial operation.

Many surgeons consider IPAA to be the appropriate recommendation in patients with FAP. Some 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 to completely laparoscopic IPAA (CL-IPAA). In patients with UC, IPAA may not be appropriate in an emergency situation, such as perforation, toxic megacolon, and hemorrhage, and in debilitated patients with malnutrition, obesity, chronic high-dose steroids, and recent anti-TNF treatment. This decision depends on whether or not 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 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 prealbumin, 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. It may be best not to perform IPAA in patients within 8 weeks of receiving infliximab or 2 weeks of adalimumab, but instead recommend a three-stage procedure. The one additional contraindication to CL-IPAA is obesity. In obese patients, 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 enlarged skin incision around the stoma often results in deformity that contributes to difficulty with maintaining an appliance. A racquet shaped modification of the skin opening can relieve the oversizing of the stoma site.

PREOPERATIVE PLANNING

For all patients undergoing elective surgery, preoperative assessment consists of the following steps: evaluation 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 electrocardiogram when appropriate, type and screen within 72 hours of operation, and pregnancy test when applicable. Patients should consult with stoma nurses to mark the most appropriate site for the planned ileostomy. Bowel preparation may be unnecessary, but there is a movement back
to bowel preparation especially for laparoscopic cases. Laparoscopic handling of the bowel is facilitated by a bowel preparation, and the “completely laparoscopic” approach removes 4-6 ft of empty colon through a 3-5-cm incision. 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.

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 (OR) and then a rapid taper over 3 days. Patients who are currently taking prednisone receive a 10-20-mg higher dose of methylprednisolone (on mg/mg basis) and then are tapered over 3 days to the preoperative dose. In accordance with Enhanced Recovery after Surgery (ERAS) guidelines, patients are given a carbohydrate load by asking them to take 12 oz of apple juice 2 hours before their scheduled time for surgery. We also prescribe oral acetaminophen, along with gabapentin and celecoxib (titrated to age and renal function, respectively) in the preoperative area.

Surgical Infection Prevention guidelines are followed. All patients are preoperatively given a warming blanket because this contributes to the maintenance of perioperative 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 eggcrate 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 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 (3M, MN, US), 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 moved into all the potential extreme positions used during the procedure 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. Second, a medial-to-lateral approach involves sacrificing the ileocolic pedicle. Although these vessels may ultimately be taken to obtain adequate length of the pouch, sometimes the length-limiting structure is the adjacent vessel arcade, and the ileocolic pedicle is preserved until final decisions are made regarding pouch “reach” (the ability of the pouch to be anastomosed to the anal sphincter without tension). Third, in a medial-to-lateral approach, the intra-abdominal colon is devascularized early in the procedure before dissection in the pelvis; a lateral-to-medial approach avoids “dead gut” sitting in the abdomen while the pelvic dissection is completed. Finally, this approach allows for a “division of convenience” of the mesentery, avoiding dissection of the proximal vascular pedicles in a patient whose tissues may be friable from prolonged steroid use.

There are essentially three components to the laparoscopic portion of the procedure: mobilization of the left colon, mobilization of the right colon, and dissection of the rectum in the pelvis. Again, there is a rationale for this approach: The left colon is somewhat more technically challenging than the right, and once this is achieved, mobilization of the right colon is a little bit of a break before the technical challenges of the pelvic dissection! Also, even if the rectal dissection requires an open approach by those surgeons not comfortable with the laparoscopic approach, the subsequent lower midline or Pfannenstiel incision is smaller than a long midline incision required to mobilize the splenic flexure.

FIGURE 30-1 Left lateral peritoneal reflection.

Laparoscopic Approach

A cutdown technique is used for insertion of a 10/12-mm blunt port. Our population of colorectal patients is sufficiently complex that a Veress needle technique is never used. After a pneumoperitoneum of 13 mmHg is achieved, the abdominal cavity is explored, and a 5-mm port is placed in the suprapubic midline and one or two additional ports (depending on body mass index [BMI]) are placed in the left lower quadrant. A diskof skin and subcutaneous fat are excised from the premarked ileostomy site in the right lower quadrant, and a 12-mm port is placed through this site.

Left Colon Mobilization

Commencing at the left pelvic brim, the dissection starts immediately medial to the left lateral peritoneal reflection. By leaving the peritoneal reflection “with the patient,” the plane of dissection identifies the left ureter, which can be gently swept laterally and protected. The sigmoid colon is mobilized to the midline, and the left lateral peritoneal reflection alongside the descending colon is opened and the descending colon is mobilized medially(Fig. 30-1).

The splenic flexure may be mobilized by several approaches. The easiest is in the patient with a normal BMI. Laterally, the proximal descending colon is dissected off Gerota’s fascia and as the plane of dissection turns medially, the lesser sac is identified, and the omentum is dissected off the distal transverse colon in a retrograde fashion. In heavier patients, the lateral dissection is the same, but instead of proceeding in a retrograde fashion once the plane of dissection has turned around the splenic flexure, attention turns to the mid-transverse colon. The lesser sac is identified and entered above the mid-transverse colon, and the dissection is continued laterally toward the splenic flexure (Fig. 30-2). The lesser sac may be entered above the colon, dividing the gastrocolic attachments and
thereby taking the omentum with the specimen, or between the omentum and distal transverse colon, thus preserving the omentum.