Daniel P. Geisler, Deborah S. Keller and Eric M. Haas (eds.)Operative Techniques in Single Incision Laparoscopic Colorectal Surgeryhttps://doi.org/10.1007/978-3-319-63204-9_15

15. Single-Incision Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis

Gilles Manceau¹ and Yves Panis¹

(1)

Department of Colorectal Surgery, Pôle des Maladies de l’Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), 100 boulevard du Général Leclerc, 92110 Clichy, France

Yves Panis

Email: yves.panis@aphp.fr

Keywords

Restorative proctocolectomyIleal pouch-anal anastomosisSingle-port laparoscopySingle incisionMinimally invasive surgery

Introduction

Ileoanal anastomosis after proctocolectomy was first described in 1947 by Ravitch and Sabiston [1]. Although this procedure spared patients from having a definitive stoma, the ileum was brought through the anal sphincter to the anal skin with a hand-sewn end-to-end anastomosis, which was associated with unacceptable stool frequency. In order to improve functional results and quality of life, in 1978, Parks and Nicholls [2] reported an alternative procedure with an ileal reservoir. It combined a Kock continent ileostomy and the removal of all remaining mucosa of the rectum below the peritoneal reflection. Their ileal pouch reservoir with an “S” configuration was then anastomosed to the dentate line using a perianal suturing technique. Subsequently, many improvements and modifications have been made. Currently, ileal pouch-anal anastomosis with a J configuration is considered the surgical technique of choice. It produced good long-term functional outcomes, with six semi-formed bowel movements per day and minimal incontinence.

The two major indications for proctocolectomy with ileoanal pouch construction are ulcerative colitis refractory to medical therapy and familial adenomatous polyposis. For these two pathologies, the surgical approach must be laparoscopy. Indeed, laparoscopic ileal pouch-anal procedures for ulcerative colitis offer improved short- and long-term advantages compared with an open approach, with faster recovery of bowel function, shorter length of hospital stay, and a reduced rate of small-bowel obstruction and incisional hernia [3]. Furthermore, for women of childbearing age with a desire for pregnancy, laparoscopy is the preferred surgical approach, as it is associated with a reduction in adhesion formation and a decreased risk of postoperative tubular infertility [4, 5]. Single-incision laparoscopic surgery may be the next evolution of the conventional laparoscopic approach by further reducing surgical trauma. To date, only six studies and one case-report reported promising results of single-incision restorative proctocolectomy with ileal pouch-anal anastomosis in adults, with a total of 51 patients [6–12].

In this chapter, we will describe the different steps of our routine surgical technique for restorative proctocolectomy with ileal pouch-anal anastomosis performed by single-port laparoscopy .

Steps of the Procedure

1.

Single-port placement (supine)
2.

Splenic flexure takedown (left side elevated, reverse Trendelenburg)
3.

Left hemicolectomy (left side elevated, steep Trendelenburg)
4.

Proctectomy (left side elevated, steep Trendelenburg)
5.

Right hemicolectomy (left side down, Trendelenburg)
6.

Hepatic flexure takedown (left side down, reverse Trendelenburg)
7.

Specimen extraction and J-pouch creation (supine)
8.

Return of the small bowel to the abdomen and assuring the pouch reaches (steep Trendelenburg)
9.

Anastomosis (steep Trendelenburg)
10.

Creation of a diverting loop ileostomy (position is supine)

Tips and Tricks

If performing a 3-stage procedure, the modification is that a subtotal colectomy is performed with an end ileostomy at the site of the single access port, and the pouch is created at a later stage.
- Briefly, the single access port was placed in the right lower quadrant at the site of the previous marked ileostomy. Dissection of soft tissues, colorectal mesentery, serosal preparation, and vascular division were achieved with the use of an energy device. The colon specimen was removed through the wound protector at the access site, and ligature of the main ileocolic artery was performed extracorporeally. Then, both sigmoid (above the rectosigmoid junction) and ileum (close to the ileocecal junction) were divided extracorporeally (with stapler). An end ileostomy is matured in the right iliac fossa, and the stapled rectosigmoid stump returned to the abdomen or alternatively matured as a sigmoidostomy in the same orifice
Once the left colon is fully mobilized and the rectum transected, we suggest bringing them over the small intestine, and passing the small bowel under the colon to the left paracolic gutter. Indeed, if this maneuver is not performed, the mesentery can cause an obstacle for the specimen extraction
The ileocolic pedicle should be divided extracorporeally. Indeed, this pedicle prevents the ileal mesentery from twisting during specimen extraction
During division of the mesenteric root, we recommend placing the patient in a steep Trendelenburg position with right side up. The entire small bowel then falls into the left upper quadrant, which facilitates dissection and visualization of the duodenum
If it is expected to place a suction drain in the pelvis at the end of the procedure, an additional 5 mm port can be inserted in the left iliac fossa and later used as the drain site. This port can be used to help the surgeon during mobilization of the splenic flexure and to retract the anterior peritoneal reflection during pelvic dissection. The laparoscope can also be introduced through this port to improve visualization and to avoid conflict and collisions between the operative instruments and the camera

Expanded Steps of the Procedure

1.

Single-port placement (position is placed supine, modified lithotomy)

No bowel preparation is needed prior to surgery. After general anesthesia induction, patient is placed supine in the modified lithotomy position. The body must be well positioned and attached to the table to prevent any patient slippage or nerve injury during the procedure, which requires exaggerated Trendelenburg and lateral positioning. Decompression is accomplished with an orogastric tube and a Foley catheter.

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