Laparoscopic TME with colonic J Pouch

Clinical History:

• 10mm polyp at 40cm proximal to anus, removed

• 25mm polyp nodular a sessile in the cecum, removed piecemeal with hot snare

• Multiple large mouth diverticula in the sigmoid and descending colon

• Rectal mass as described-biopsied

• Mass base of cecum-fragments of tubular adenoma

• Sigmoid 40cm polyp-hyperplastic

• Mass rectum - fragments of tubular adenoma with high grade dysplasia

Procedure Steps:

• Modified lithotomy position

• Three port technique in through umbilical, right lower quadrant, right upper quadrant ports

• Mobilize lateral to medial approach to mobilize left colon

• High ligation of inferior mesenteric artery, vein, and splenic flexure

• Total mesorectal excision

• Stapler transection

• Division of mesentery from high ligation to sigmoid descending junction

• Extracorporealization through an enlarged umbilical port incision through which a wound protector is placed

• Fluorescence angiography with resection of specimen and construction of colonic J-pouch

• Stapler introduction with anastomosis

• Placement of drain and creation of ileostomy

Learning Points:

• Only three ports needed

• Mobilize splenic flexure, IMA and IMV for length

• Create colonic J-pouch to optimizing function

• Utilize endoscopy to help assess anastomotic integrity

• Employ ICG to evaluate perfusion