Dr. Meagan Costedio

Single Port Total Proctocolectomy with Ileal Pouch Anal Anastomosis

Case The patient is a 29 year old male with 9 yr history of UC.  At the time of diagnosis he was initially treated with asacol and prednisone, and azathioprine added with good results for 1 yr.  He was feeling worse and referred to CCF GI. On april 2014 a colonoscopy showed moderately inflamed mucosa throughout the colon and a 6mm polyp in the sigmoid colon. The Pathology showed an Adenoma-like low-grade dysplasia arising in a background of chronic active colitis, in the sigmoid polyp and transverse nodular mucosa. At surgical consultation it was discussed to perform one more colonoscopy to confirm diagnosis and rule out sporadic adenomas.  He was also started sulfasalazine for his symptoms. Repeat colonoscopy on September 2014, inflammation was found from the rectum to the cecum quiescent compared to previous examinations. Focal areas of nodularity more prominent in right colon. Random biopsies in the sigmoid: Flat low-grade dysplasia arising in a background of chronic active colitis with mucosal eosinophilia, the rest: chronic active colitis with eosinophilia. Treatment With 2 subsequent biopsies confirming low grade dysplasia in this young gentleman we discussed the risks and benefits of surgery as a treatment for his colitis and he agreed.  With the presence of low grade dysplasia in the sigmoid and transverse colon the plan was to proceed with high ligation of the vessels as well.   A 2-2.5 cm stoma site incision is made in the place of the previously marked ileostomy site.  The abdomen is entered in a Hasson technique and a single incision device is placed. Standard laparoscopic instruments are used with a flexible tipped 5mm camera.  Both the operating surgeon and assistant stand on the left side of the patient and the patient is tipped in the left side down and trendelenburg position.   Attempt is made to identify the duodenum through the right colon mesentery as you can see. The terminal ileum is directed to the pelvis and the remainder of the small bowel is placed in the left lower quadrant. The Ligament of Treves is grasped and pulled anteriorly and laterally to expose the ileocolic vessels.   The peritoneum proximal to the vessels is scored and the avascular plane between the retroperitoneum and posterior mesentery is developed. The goal is the find the duodenum early in the dissection to ensure the appropriate dissection plane anterior to the duodenum.  The ileocolic vessels are taken above the duodenum about 1 cm distal to the SMA. The avascular plane is developed bluntly as laterally and cephalad as possible.   The bowel is then moved to the left upper quadrant. The right ureter is easy to identify, and the small bowel mesentery and appendix are retracted cephalad. The prior dissection plane is identified and the lateral attachments are taken as the colon is retracted to caudally and to the left. At this point it is comfortable for the operating surgeon to transition to between the legs and for the camera operator to stand to the right or left of the table.  The hepatocolic attachments are taken here. For an oncologic dissection it is best to enter the lesser sac prior to taking the mesentery of the transverse colon. The lesser sac is entered here in the mid transverse colon and the lesser omentum is taken off the colon avoiding the gastroepiploic vessels to the splenic flexure. The colonic mesentery is dissected free from the duodenum and the pancreas and the mesentery taken.  With the lesser omentum dissected free it is possible to retract the stomach cephalad to see the root of the mesentery.  It is imperative to remember that the fourth portion of the duodenum enters the transverse mesocolon in this area, so both sides of the mesentery need to be visualized prior to taking the mesentery to avoid duodenal or gastric injury. At this point the table is in the reverse trendelenburg and right side down position and both surgeons are usually on the left side. This dissection is continued up to the splenic flexure where the mesentery splays to the left colon. The table is then placed in the trendelenburg and steep right side down position and the IMA is identified. The peritoneum is scored and the ureter and gonadal vessels are identified. A medial to lateral dissection is performed and the IMA is taken in a high ligation after the hypogastric nerves have been dissected free and the ureter identified.  The medial to lateral dissection is continued up to the splenic flexure as much as possible. You can see the importance of hand over hand dissection with the single incision technique with for exposure. The colon is retracted medially and the lateral attachments are taken and the dissections are joined. The colon is medialized up to the flexure and the left colon mesentery is taken which joins the dissection from the transverse and the colon is completely free. The rectum is then approached. The operating surgeon is most comfortable on the right side of the patient and the camera operator on the right.  The patient is maintained in the steep trendelenburg position and attempt to plane flat left to right, though right side down is often needed due to small bowel.    The presacral plane has previously been identified from the medial to lateral approach and the nerves swept posteriorly.  The mesorectum is gently dissected down to the pelvic floor.  The dissection is continued down in the posterior approach to the pelvic floor. The rectum is retracted anteriorly and out of the pelvis to place the presacral fascia on appropriate tension.  Some blunt dissection is necessary in the deep pelvis below Waldeyer’s fascia to pull the rectum off the levators posterior and prepare the rectum for stapling. Using rectal retraction to the right and left the lateral peritoneal attachments are taken and the anterior peritoneal reflection are scored.  Where there is not a known cancer in a young man it was decided to take the mesorectal envelope posterior to Denonvillier’s fascia. It is essential to dissect the mesorectum free circumferentially to the levator complex to not leave a long rectal stump. The rectum is held anteriorly and is stapled anterior to posteriorly to make a straight staple line.  I prefer to use a 45 mm stapler below the peritoneal reflection which increases the maneuverability of the stapler in a tight space.   The staple line is grasped and the colon is brought out through a wound protector. Occasionally the stoma site with need to be enlarged for specimen extraction. A 15-18cm J pouch is created and the pouch is checked with air and betadine for leaks which are oversewn prior to anastomosis.  The circular stapler anvil is pursestringed in and the J pouch is returned to the peritoneal cavity. This is another step in which the stoma site may need to be enlarged to fit the pouch without trauma.   The mesentery of the J pouch is then dissected free over the duodenum for maximal reach and the mesentery is ensured to be straight prior to creation of the anastomosis. The anastomosis is then tested with flexible sigmoidoscopy for air leak and to look for bleeding and to check that the anastomosis is 2-3 cm above the dentate line.  A pelvic drain is placed and diverting stoma is created 15 cm proximal to the pouch Outcome The final pathology returned chronic active colitis with low grade dysplasia in the sigmoid colon. The stoma was reversed 8 weeks later after negative gastrograffin enema.