Indications of transanal approach for complicated inflammatory bowel disease

Clinical Case

A 31-year-old female patient with a history of ulcerative colitis had undergone a total Proctocolectomy using a combined transabdominal and transanal approach (Cecil approach) to perform an ileoanal pouch. In addition, a loop ileostomy was made and subsequently closed after checking the anastomosis. Pathological examination showed a tubulovillous adenoma adenoma with low grade dysplasia on the rectal remnant close to the anastomosis, so periodic endoscopic controls were performed. However, during the last mucosal endoscopic resection, the finding was a  tubulovillous adenoma with changes of adenocarcinoma and positive margins.

Treatment

It was decided to perform a resection of the anastomosis with mobilization of the ileoanal pouch through a combined abdominal and transanal approach. Once the transanal platform was introduced, the area of the anastomosis revealed an irregular mucosa. The rectal mucosa was tattooed with a cautery hook to ensure the distal margin of resection and guide the initial phase of the dissection. Subsequently, a careful dissection of the rectal mucosa was made, attempting to advance to the anastomosis in order to mobilize the pouch. We can observe that the tissue presents an important fibrosis due to previous surgery, which makes the procedure more difficult. During the anterior dissection, especial care was taken in order to avoid a vaginal injury. The dissection continued from distal to proximal, by means of the hook, going near the intestinal wall without injuring it. It is important to note that as in a total mesorectal excision, the dissection must be kept circumferential, from down to up, trying to always be working in the same plane. Once the area of the anastomosis was passed, it was important to be very careful not to injure the ileal pouch, even performing dissection with scissors when necessary. In case of hemorrhage we usually use bipolar, which also serves to dissect the different layers. Step by step, the dissection progressed towards the abdominal cavity. A good maneuver is the use of a gauze to push the specimen providing exposure and continue working on the dissection. At this point we can see how the adhesions are looser and are easily released with the scissors. In this phase of the surgery the abdominal team will help tractioning from the pouch to have tension and to favor the work from the transanal approach. Finally both teams joined their dissection planes. At this point, the transabdominal and the transanal teams can work simultaneously and assist each other to improve traction and identify the correct planes. With the assistance of both teams, the pouch dissection continued anteriorly and laterally towards the posterior side in order to completely release it. Once the pouch was released transanally, the mobilization of its proximal part  was completed  from the abdominal approach. At this point, the specimen is completely free and can be mobilized for transanal extraction, resection of the anastomosis area and preparation of a new coloanal anastomosis. The pouch is pulled distally by the transanal team to complete the procedure with a new ileoanal handsewn anastomosis without tension. In this case, an ileostomy was not performed.

Outcome

Operative time was 120 minutes.  Patient resumed oral intake 8 hours after the surgery and was discharged on the 3^th postoperative day. Pathological examination confirmed fibrosis without any signs of dysplasia or neoplasia. One month after surgery, the patient is in a good general condition and presents a correct anorectal functionalism.