Pure laparoscopic robotic total proctocolectomy with transabdominal robotic anal mucosectomy

Clinical Case

This is a case of a 30-year-old woman with a diagnosis of Ulcerative Colitis with poor medical control. Due to worsening bloody stools and the presence of recto-vaginal fistulae , we decided to perform a total proctocolectomy with end ileostomy.

Treatment

We performed a laparoscopic colectomy and a robotic proctectomy. We don´t show the first part of the surgery consisting on mobilization of right colon, transverse colon and splenic flexure. We performed a medial-to-lateral mobilization using the inferior mesenteric vein as the initial landmark. The peritoneum under the inferior mesenteric vein is incised, and the space between the mesocolon and Gerota´s fascia were developed bluntly toward the abdominal wall, superiorly toward the inferior edge of the pancreas, and inferiorly toward the inferior mesenteric artery. The inferior mesenteric vein was then divided to facilitate further mobilization. Distally, the inferior mesenteric artery was divided at its origin after identification of the ureter and gonadal vessels. The da Vinci system was now docked coming in over the patient’s left hip. The assistant surgeon remained on the right side of the patient and helped with additional retraction and suctioning with additional laparoscopic ports. The rectosigmoid mesentery was elevated superiorly and anteriorly with the left robotic arm so that the plane between the fascia propria of the rectum and the parietal fascial could be entered. This plane consists of fine areolar tissue that can be divided sharply with the monopolar scissors all the way to the level of the coccyx. Ureters remain lateral to the dissection, whereas the hypogastric nerves lie posterior, and care is taken to preserve them. The lateral stalks of the rectum can be divided with monopolar or bipolar cautery. We can see in the image, first the left and then the right side of the rectum. The peritoneal reflection was incised anteriorly, and the dissection continues circumferentially around the rectum until the pelvic floor was reached. We can see here at the right part of the low rectum the recto-vaginal fistulae tract . We divided it and mobilized the entire rectum. In this case we divided the ultralow rectum with monopolar scissors. We can see here the anus mucosa with inflammation and polyps . The look of the anus and the presence of the fistulae were both reasons to believe that was safer not perform primary anastomosis in this patient, to perform an end ileostomy and to make the ileoanal pouch in a posterior surgery. The specimen was extracted transanally, avoiding any abdominal incision and performing in this way a pure laparoscopic robotic procedure. The long arms of the da Vinci Si robot reach easily all the way across the pelvic floor and allowed us to perform the anal mucosectomy transabdominally. Laparoscopic surgery has become an accepted method for the treatment of colorectal diseases, resulting in superior short-term functional outcome and equivalent long-term oncologic outcomes in cancer cases. Despite these benefits, laparoscopic rectal surgery remains a challenging procedure with conversion rates as high as 30%. Robotic technology is especially suitable for dissection in confined spaces such as the pelvis, in which three-dimensional vision and increased dexterity help in the performance of delicate operations such as a total mesorectal excision or prostatectomy. Here we have a perfect view of the pelvic floor and the puborectalis muscle. In an attempt to facilitate the next surgery, we closed the anus with a continuous suture of monofilament. The development of robotic systems such as the da Vinci has made it possible to overcome many limitations of conventional laparoscopic surgery such as lack of three-dimensional vision, compromised dexterity with limited range of motion, poor ergonomics, and amplification of physiologic tremor.

Outcome

The postoperative stay was uneventful and the patient was discharged on postoperative day three. The pathological analysis showed a chronic proctocolitis involving the sigmoid and rectum with moderate-to-severe activity.  No dysplasia or malignancy was identified.