CHAPTER 23 Total proctocolectomy with ileal-pouch anal anastomosis
Step 1. Surgical anatomy
♦ Chronic ulcerative colitis (CUC) is an inflammatory bowel disease limited to the mucosa of the rectum and colon. Although no etiologic factor has been identified, population studies suggest there is both a genetic and an environmental component contributing to the development of CUC. The disease course is characterized by intermittent flares of disease activity. Medical therapy for the intestinal manifestations of CUC is directed at controlling symptoms by modulating the inflammatory process. To date, no medical therapy is curative. However, surgical removal of the colon and rectum cures the intestinal manifestations of the disease and eliminates or markedly reduces the associated risk of malignancy in long-standing CUC. Surgical intervention for CUC is divided into two broad categories, emergent and elective, that will influence the type of surgery performed. Emergency operations are directed at life-threatening complications of CUC and are not intended as definitive surgical treatment for CUC. Alternatively, elective surgery is intended as a definitive treatment for the intestinal symptoms. In appropriately selected patients, the best surgical option is the total proctocolectomy with an ileal pouch-anal anastomosis (IPAA). The IPAA avoids the need for a permanent stoma while maintaining the normal route of defecation.
♦ This is a technically demanding operation and should be performed by surgeons comfortable with both the technical aspects of the procedure and management of the many possible complications. Traditionally, this complex operation has been performed through a midline laparotomy. However, improved technology and increased surgical experience with advanced laparoscopy have permitted a number of surgeons and centers to offer a minimally invasive approach to the IPAA procedure. Although the initial laparoscopic IPAA experience was characterized by long operative times, experience and new technology have significantly reduced operative times while maintaining the safety and clinical outcomes, making the laparoscopic IPAA comparable to the open procedure.
Step 2. Preoperative considerations
Patient preparation
♦ In chronic ulcerative colitis (CUC) patients with fulminant or toxic disease, the appropriate choice of operation is a total abdominal colectomy with Hartmann pouch and end ileostomy. This operation removes the majority of the diseased organ, allows the patient to be tapered off of all immunosuppressive medications, and regain their health and nutritional status before proceeding to a definitive restorative operation (IPAA).
♦ Prior to proceeding to an IPAA, the diagnosis of CUC or indeterminate colitis needs to be firmly established. Crohn’s disease is a considered a significant contraindication for proceeding to an IPAA.
♦ Patients need to visit with an enterostomal therapist for pre-operative stoma marking and to begin education regarding the care of the stoma. Using a laparoscopic approach for an IPAA results in a significantly shortened length of stay in hospital and decreases the opportunity for education regarding stoma management.
♦ We do not routinely use oral antibiotics nor a mechanical bowel preparation as it tends to cause bowel distension with liquid stool which makes colon manipulation more difficult. Each patient receives one or two tap water enemas the morning of operation.
♦ The operating room requirements for an efficient laparoscopic TPC-IPAA include:
an electronically controlled operating table with a significant range in side to side tilt and steep Trendlenberg and reverse Trendlenberg capability to facilitate the use of gravity to move the small intestine out of the way of dissection.
♦ All patients require a padded chest strap placed securing them to the table. They need to be positioned in modified Lloyd-Davies lithotomy with both arms padded, protected, and tucked against their torso. The patient’s legs are placed in leg holder that allows the hips and thighs to be flat with respect to the abdomen but the lower leg to be positioned downward (i.e. Yellofin® Stirrups, Allen® Medical Systems). These leg holders minimize the chance of patient movement on the table during positioning changes as well as permitting access to the perineum for placement of a circular stapler or a vaginal retractor/manipulator.
♦ In patients who have recently received or are currently on steroids, a brief pulse of steroids is appropriate during the peri-operative period.
Room setup and patient positioning
♦ The patient is placed in the modified lithotomy with both arms padded, protected, and tucked against the torso. It is important that the thighs are positioned in such a way that they are level with the abdomen. A chest strap is applied to minimize the risk of the patient shifting on the operating table during frequent position changes during the procedure. Ideally, video monitors are available on movable booms to permit placement above the patient’s left and right shoulders and one in the area between the patient’s legs during different phases of the operation.
Step 3. Operative steps
Laparoscopically-assisted (LA) approach
♦ A diamond configuration for trocar placement is used. Four trocars, three 5-mm and one 10–12-mm are placed.
♦ A 10-12 mm trocar is placed in the future ileostomy site after an open technique is used to enter the abdomen. Pneumoperitoneum is established and laparoscopic exploration of the abdomen is undertaken with a 5 mm 30 degree laparoscope to assess the feasibility of proceeding with a minimally invasive approach.
♦ Extensive adhesions, unanticipated anatomic or inflammatory processes that preclude a minimally invasive should prompt immediate conversion to an open procedure.
♦ The remaining 5-mm trocars are placed under direct vision in a diamond configuration with one in the left lower quadrant, one in the midline in the suprapubic position, and the last one in the midline above the umbilicus (Fig. 23-1).
♦ During the procedure, the first assistant is always standing across from the surgeon while the camera operator is positioned next to the surgeon. For the majority of the procedure, the camera will be used in supraumbilical trocar.
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