Laparoscopic proctectomy with ileoanal anastomosis for inflammatory bowel disease

Total coloproctectomy with ileal pouch-anal anastomosis is the operation of choice for ulcerative colitis. The objective of this video is to demonstrate the technique used to perform a laparoscopic coloproctectomy for the treatment of inflammatory bowel disease (and particularly, ulcerative colitis) and to show the ileoanal anastomosis (with creation of an ileal J-pouch) that follows a total colectomy resection. In this case, only sample exteriorization and ileal J-pouch formation are performed using the temporary ileostomy opening situated in the right flank. All other steps are performed entirely laparoscopically. The dissection is carried out using the 10mm Ligasure Atlas device.

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Laparoscopic proctectomy with ileoanal anastomosis for inflammatory bowel disease

Authors

J Leroy, J Marescaux

Abstract

Total coloproctectomy with ileal pouch-anal anastomosis is the operation of choice for ulcerative colitis. The objective of this video is to demonstrate the technique used to perform a laparoscopic coloproctectomy for the treatment of inflammatory bowel disease (and particularly, ulcerative colitis) and to show the ileoanal anastomosis (with creation of an ileal J-pouch) that follows a total colectomy resection.
In this case, only sample exteriorization and ileal J-pouch formation are performed using the temporary ileostomy opening situated in the right flank.
All other steps are performed entirely laparoscopically. The dissection is carried out using the 10mm Ligasure Atlas device.

Classification

basic techniques

Keywords

Laparoscopic coloproctectomy, panulcerative colitis, ileal J-pouch anastomosis, ulcerative colitis, IBD, inflammatory bowel disease

Media type

Surgical video

Duration

13'54''

Publication

2009-03

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Subtitles

E-publication

WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2509.htm

Laparoscopic proctectomy with ileoanal anastomosis for inflammatory bowel disease

1. Introduction 00'10''

The objective of this video is to demonstrate the technique used to perform a laparoscopic proctectomy for the treatment of inflammatory bowel disease (and particularly, ulcerative colitis) and to show the ileoanal anastomosis (with creation of an ileal J-pouch) that follows a total colectomy resection. The first operative step is to perform a laparoscopic total colectomy.

2. Start of the rectal dissection 00'50''

We can then begin the proctectomy. This manoeuvre is facilitated by division of the sigmoid mesocolon. Anterior and cephalad traction is exerted on the rectum. The dissection performed is different to that of rectal cancer surgery. In this male patient, we use the 10mm Ligasure Atlas device. We could certainly use a smaller diameter, but the 10mm one is less traumatic. We use this device to perform a division in contact with the rectal tube, hence extending the division of the sigmoid mesocolon that is also carried out proximal to the colon. The mesorectum’s vascularization is therefore preserved; this is useful as it helps to avoid a presacral defect through which the pouch may fall. The other advantage is to dissect in contact to the rectum, and distal to the nerve plexuses that can be found much more laterally.

3. Anterior rectal dissection 02'14''

This is all the more important anterior to the rectum where the dissection is begun by opening the peritoneum in contact to the rectal wall very much above the Douglas’ pouch. To the left, thanks to traction and counter-traction achieved by the instrument introduced in the right iliac fossa, we carry out a division staying parallel to the rectal wall. The dissection is continued slowly and anteriorly while keeping in contact to the rectal wall and distal to the Denonvilliers’ fascia.

4. Posterior rectal dissection 03'01''

Here we can see that the posterior dissection is still pursued in contact to the rectal wall, leaving the mesorectum posteriorly with a fat pad that will later accommodate the ileal pouch. The 10mm Ligasure Atlas device is used like a finger and helps to dissect the planes before dividing the vascular tracts. The dissection is then continued from posterior to anterior, and from right to left, hence allowing for a better traction on the lower rectum as the dissection is carried out. A retractor introduced suprapubically exerts an anterior traction on the vesicorectal peritoneum, and helps to stay distal from the Denonvilliers’ fascia. As you can see here, the dissection is continued in contact to the rectal wall. This allows to progressively divide the rectum until we have almost reached the pelvic floor. If this is not possible, care must be taken to dividing the posterior attachments and to keeping the rectal stump as short as possible; this rectal stump is then resected transanally as will be seen later on.

5. Pelvic dissection 05'02''

Division may be carried out until the sphincter is reached. Control of bleeding is facilitated by the use of versatile instruments such as the Ligasure Atlas, as it allows for elective coagulations, avoids constant instrument changing and is risk-free for adjacent tissues. As can be seen here, the dissection is continued up to the pelvic floor. On the posterior aspect, the pelvic floor muscles are clearly visible. The same manoeuvre is continued to the left and anteriorly. Especially in slightly obese male patients with a narrow pelvis, the ideal technique is to use adequate retractors such as the T-shaped retractors being used here. These retractors allow for an anterior traction and a wider opening of the rectoprostatic space where instruments are introduced to continue the dissection by always staying in contact to the rectum. This is not a case of rectal cancer and as such the dissection can be carried out with the objective of resecting the rectum. To the left, thanks to an adequate anterior traction, the dissection can be performed under visual control. Hemostasis is perfectly controlled thanks to the dissecting instrument. Once the lowermost part of the rectum has been dissected, its division may be carried out. It is unnecessary to divide in contact to the levator ani muscles. We must check that we are in the appropriate plane.

6. Rectal division 07'28''

We then use an Endo-GIA type linear stapler with a blue cartridge in order to completely divide the dissected rectal portion. In case of difficulties related to the narrowness of the pelvis, 30mm staplers can be used and an anterior posterior division seems easier to perform. One or two applications of the 30-45mm linear stapler are generally sufficient. Once the rectum has been divided, we check that there is no bleeding. Further hemostasis may be performed. Here we can see the adipose bed of the mesorectum that has been preserved, which will avoid the posterior tilting of the pouch when it will be brought in contact to the pelvis. Before completing the distal extremity of the rectal stump that will be done transanally, the colon and the rectum will have to be brought out.

7. External J-pouch creation 08'59''

This exteriorization is done through a small suprapubic incision protected by a plastic wound protector, or through the temporary ileostomy opening situated in the right flank as in the present case. Once the colon has been extracted, the J-pouch is created. It is about 15cm long. It is made of 2 legs of ileum, which are kept stuck together by 2 graspers situated to the two extremities as can be seen on these pictures. Through a small incision at mid-distance, the Endo-GIA linear stapler is introduced in order to perform a side-to-side anastomosis. Towards the distal extremity, it is almost impossible to perform a complete division with the stapler. Therefore, it is necessary to revert the extremity of the pouch and to place the stapler in this seromucosal bridge and complete the joining of the pouch at the level of the two legs. We must then close the stapled areas. They must be controlled to rule out any bleeding. Further hemostasis may be performed using a running suture on the posterior wall, and particularly at the level of the stapled anastomotic areas where these cross.

8. J-pouch completion 11'00''

The pouch is completed by closing the mechanical staples’ introduction hole. This closure can be achieved either by interrupted monofilament absorbable sutures (here Maxon 3/0), or by two half-running sutures that meet at the mid-part as in the present case. This is quicker to perform and ensures an airtight suture. The pouch has been created out of the abdominal cavity through an abdominal incision that serves as a temporary ileostomy incision. The extremity of the pouch has been identified thanks to a thread placed at its end. Then the pouch is brought into the pelvis before resuming the dissection transanally. The sphincter has been dilated.

9. Transanal step: ileoanal anastomosis 12'36''

Good exposure of the anal canal is ensured thanks to the use of the LoneStar retractor. The mucosa is infiltrated and then incised making sure to preserve the seromuscular mucosa with a substantial seromuscular sheath. The extremity of the pouch is then brought in the anal canal. It is opened thanks to the thread that was placed as a landmark on the extremity of the pouch. An ileoanal anastomosis is carried out using interrupted monofilament absorbable sutures (here Maxon 3/0). Once achieved, the position of the pouch is controlled to make sure that there are no bends or an inadequate placement, before building a diverting ileostomy 30cm above the ileoanal anastomosis.