Robotic Total Proctocolectomy
Elizabeth C. McLemore
Vikram Attaluri
INDICATIONS
Total proctocolectomy (TPC) with an end ileostomy is suited for only certain populations. Patients who have Crohn’s disease or those with ulcerative colitis and are unable to undergo an ileal pouch reconstruction are the most likely groups. Others include synchronous cancer patients or patients with familial adenomatous polyposis with rectal cancer preventing sphincter preservation.
Before the operation, patients should undergo an evaluation with an ostomy nurse. A well-informed patient would be better positioned to care for the ostomy. Also, the preoperative selection of an ileostomy site is also of benefit.
SURGERY
Operative Preparation
A mechanical bowel preparation with oral antibiotics should be given to reduce septic complications.
The patient should be in the lithotomy position in case a perineal approach is needed to perform a mucosectomy. The arms should be tucked.
The patient should be secured to the table with tape across the chest at the level of the shoulders, taking care not to restrict the breathing.
The stoma site should be marked with a scratch from a 16-gauge needle to allow identification after skin preparation.
An orogastric tube and a Foley catheter should be placed to facilitate dissection.
Operative Technique
Although there are multiple methods of performing a robotic TPC, the most efficient method is to perform the colectomy laparoscopically and then perform the proctectomy with robot assistance.
Use of a bipolar energy device is efficient and cost-effective because this device can be used to ligate all major colon mesentery vessels and used to grasp the bowel safely.
Patient positioning during the surgery is indispensable to the operation. Mobilization of the ascending colon is assisted in the Trendelenburg position, followed by reverse Trendelenburg position of the transverse colon, and finally the Trendelenburg position for the sigmoid colon and rectum.
Port Placement
Port placement is initially made to allow for robotic dissection of the pelvis.
A 12-mm port should be placed two fingerbreadths right of the umbilicus—see Fig. 28-1.
Robotic 8-mm ports should be placed in the right lower quadrant and the left lower quadrant and the left lateral abdomen. The ports should be 8-10 cm apart from the nearest port.
A 5-mm assistant port can be placed in the right upper quadrant at least 5 cm away from the nearest robotic port.
Additional 5-mm ports can be placed as needed to assist in the dissection, usually in the midline epigastric or suprapubic ports.
 FIGURE 28-1 Port placement. |
Mobilization
Dissection of the right colon begins with the surgeon at the left side of the patient.
Using the lateral attachments of the ascending colon to provide suspension of the colon and counter traction, dissection begins in a medial-to-lateral manner with ligation of the ileocolic artery.
The lateral attachments are then dissected to meet with the medial dissection. Care is taken to medialize the terminal ileum to ensure it will reach the ileostomy site.
Attention is then turned to the hepatic flexure. The transverse colon is mobilized away from the liver toward the hepatic flexure until the prior dissection is met.
As the dissection continues distally, the surgeon will move to the right side of the patient.Related posts:
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