Advantages of the Cecil approach for bowel transit restoration

This video will show the benefits of the Cecil approach for bowel transit restoration. The patient is placed in the Lloyd Davies position in every case and transanal and abdominal laparoscopic access platforms are placed. This approach is performed simultaneously, both laparoscopically and transanally, using GelPOINT devices.

The first step is to release the stoma from the abdominal wall.  The incision can be used to build a J pouch or just to place the EEA anvil shaft and prepare the bowel for the future anastomosis.

Then we place the single access platform through the stoma wound, having previously placed a 12 mm umbilical trocar for 30º scope. We place the pneumoperitoneum in the umbilical trocar and finish by adapting the single port with 2 working trocars. Simultaneously, we make the transanal approach through the other single-port device. The previous stapler line is resected transanally and the proximal rectum and mesorectum are dissected up to the peritoneal reflexion, where both teams work together to complete the adhesiolysis.

Usually in the abdominal field, as in this case , there are several adhesions of the small bowel to the pelvis due to the chronic inflammatory process. The transabdominal team takes down the adhesions while the transanal surgeons dissect the rectal stump. There is a high degree of fibrosis and the tissues tend to bleed.

The maneuvers progress and the teams’ dissections meet, helping to identify the unclear surgical planes and respecting the pelvic vessels and ureters. We have found that transanal access provides additional benefits during the dissection of a complicated pelvis, as in men, individuals with a narrow pelvis, fibrotic mesorectum, and obese patients. Mainly, it allows for better visualisation of the surgical dissection planes, passing through untouched territory.  

Finally, an anastomosis is performed under laparoscopic control. In this case ileorectal anastomosis with a preformed pouch. The achievement of a new distal margin after the excision of the proximal bowel stump and the construction of an anastomosis that is free of fibrosis and previous sutures, with better vasculature, are other characteristics which we would like to highlight. The transanal approach also makes it possible to review the anastomosis and perform a hemostasis if necessary.

This approach can be useful in bowel transit restoration, particularly in patients with a high probability of peritoneal adhesions and small rectal stumps. Two surgical teams working simultaneously can assist each other by performing traction and contra-traction on the rectal stump.

As with any new surgical procedure, it is probably too early to draw conclusions, but the Cecil approach currently seems to be a safe and feasible technique to perform a bowel transit restoration.