Laparoscopic restorative proctocolectomy ileal pouch anal anastomosis: How I do it?

Surgery for ulcerative colitis is a major and complex colorectal surgery. Laparoscopy benefits these patients with better outcomes in context of cosmesis, pain and early recovery, especially in young patients. For surgeons, it is a better tool for improving vision and magnification in deep cavities. This is not the simple extension of the laparoscopy training. Starting from preoperative preparation to post operative care there are wide variations as compared to open surgery. There are also many variations in steps of laparoscopic surgery. It involves left colon, right colon and rectal mobilisation, low division of rectum, pouch creation and anastomosis of pouch to rectum. Over many years after standardisation of this technique, it takes same operative time as open surgery at our centre. So we present our standardized technique of laparoscopic assisted restorative proctocolectomy and ileal pouch anal anastomosis (IPAA).

INTRODUCTION

Incidence of ulcerative colitis in India is roughly six cases per 100000 population per year and prevalence being approximately 44 cases per 100000.[1] Indians are more vulnerable to extensive disease compared to other Asian populations.[2] Though overall incidence of colectomy in these patients have decreased, quality of life is excellent in more than 90% patients after pouch surgery.[34] Surgical outcomes are similar in patients of south Asian and non Asian ethnicity.[5] Long term outcome are not found different for laparoscopic or open approach by majority of study groups and even Cochrane reviews, though early recovery after laparoscopic surgery for UC is well established.[6] So, here we present the standardized technique of laparoscopic assisted restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) followed at our centre.

PREOPERATIVE PREPARATION

For patients requiring restorative proctocolectomy with ileal pouch surgery in planned setting, indications for laparoscopy don’t differ from open surgery. Fitness of patient to tolerate prolonged general anaesthesia is assessed. History of previous abdominal surgeries through large incisions is relative contraindication. Patients presenting in emergency setting i.e. toxic megacolon, colonic perforation are not usually chosen for laparoscopy. As majority of our patients undergo two stage surgeries with diverting ileostomy, preoperatively patient is counselled for stoma site and care. Possible conversion to laparotomy is also explained. Mechanical bowel preparation is done with polyethylene glycol solution one day prior to surgery; then patient is kept on clear liquids orally. Patient is kept nil by mouth for eight hours prior to surgery, with intravenous maintenance fluids. Deep vein thrombosis (DVT) prophylaxis in form of low molecular weight heparin 12 h prior to surgery is given, with DVT stockings in all patients. DVT pump is used intra-operatively in patients with high risk of DVT. Local preparation of abdomen is done as for major abdominal surgery. Stoma site is marked with skin marking pencil. Intravenous prophylactic antibiotics are given at the time of induction of anaesthesia.

POSITIONING OF PATIENT AND PORTS

Patient is positioned in Trendelenberg with low lithotomy, both arms by side of patient and tucked in. Popliteal fossae are protected with adequate padding [Figure 1]. Extensions are used for IV lines. Two monitors are required on both sides of patient. Urinary bladder is catheterized with adequate size of Foley's catheter. After induction of anaesthesia parts are prepared. Pneumoperitoneum is created with Veress needle and metalic flap port of 10mm size is inserted through infraumbilical midline vertical incision. 12mm working port in right iliac fossa (RIF) is placed just lateral to mid-clavicular line and below level of McBurney's point. Five mm ports are inserted in right upper quadrant (RUQ) and left upper quadrant (LUQ) at mid clavicular line and in left iliac fossa (LIF) at mid-clavicular line at point corresponding to McBurney's point on right side [Figure 2]. Pressure of pneumoperitoneum is set at 12mm of Hg and flow at ten L/min.

Figure 1

Showing position of patient

Figure 2

Showing port placement

OPERATIVE STEPS

Entire procedure is divided in three major steps. First is laparoscopic mobilisation of whole colon with rectum. Second is mini laparotomy with specimen removal and creation of pouch outside abdomen. Third is re-laparoscopy and pouch anal anastomosis intracorporeally with covering ileostomy and closure.

After placement of all ports, surgeon starts left colectomy standing on right side of patient. Camera surgeon stands on right side of patient to left of surgeon and assistant surgeon stands on left side of patient. Both right sided ports are used by surgeon, RIF port for working instrument and right upper quadrant port for providing counter traction. Assistant surgeon uses both left sided ports for providing traction to part of colon to be dissected with Endoclinch graspers. In steep Trendelenberg position small intestinal loops are placed in upper abdomen and sacral promontory is identified [Figure 3a]. After identifying right ureter [Figure 3b], sigmoid colon is grasped in direction of inferior mesenteric vessel pedicle and then posterior peritoneum is incised with monopolar cautery attached to spatula [Figure 3c]. While providing traction and counter traction, handling of colon is of utmost importance. Only appendices epiplocae should be caught with grasping instruments and not the wall of colon. Direction of instruments should be in such a way to provide maximum stretch over the segment of colon that is being dealt with. Direction of instrument needs to be readjusted frequently to provide adequate traction. Left ureter and gonadal vessels are identified and then stretched inferior mesenteric vessels are bared of surrounding fatty tissue. As disease is benign, root of artery need not to be cleared till origin, which can damage superior hypogastric nerve. Dissection is carried out from medial to lateral direction creating plane between mesocolon and left Gerota's fascia [Figure 3d]. Superior haemorrhoidal (rectal) artery [Figure 4], continuation of inferior mesenteric artery is divided between Hemolock clips. Inferior mesenteric vein is sealed with Ligasure device and divided. Next, as shown in Figures 5a–d, lateral attachments are divided with monopolar cautery till splenic flexure is completely mobilised with ultrasonic shears and lesser sac is entered. Next transverse colon is separated from greater omentum as much as possible.

Figure 3

(a) Retraction of sigmoid colon holding its appendices (b) Identifying right ureter before incision over peritoneum (c) Incising peritoneum after holding IMA pedicle (d) Dissecting from medial to lateral

Figure 4

showing Inferior mesenteric artery continuing as superior haemorrhoidal artery, dissected free and ready for division after clipping

Figure 5

(a) Retraction of descending colon holding appendices (b) Incising lateral peritoneal attachments of descending colon (c) Readjusting traction and counter traction to keep lateral peritoneum stretched (d) Complete mobilisation of left sided colon upto splenic flexure

Next rectal mobilisation is done, which is similar to total mesorectal excision (TME). Care is taken to avoid injury to inferior hypogastric nerves on sidewall of pelvis during posterior dissection. Lateral pedicles are divided and haemostasis is secured by dividing middle rectal vessels [Figure 6a] with ultrasonic shears. Anterior dissection is done posterior to Denonvilliers’ fascia in males and between rectum and posterior wall of vagina in females [Figure 6b] with monopolar cautery. Dissection is done upto the level of anorectal junction, which is confirmed by per rectal digital examination by OT assistant. After achieving adequate circumferential clearance two cartridges of Endo GIA 45 mm roticulating stapler are fired [Figure 6c], leaving 1–2 cm rectal stump [Figure 6d].

Figure 6

(a) Dissection of lateral pedicles of rectum (b) Anterior dissection of rectum below peritoneal reflection(c) Adjusting Endo GIA roticulating 45mm stapler over rectum at proposed line of division after confirmation (d)Rectal stump after low division of rectum with stapler

The next step is right colon mobilisation, for this surgeon and camera surgeon shift to left side and assistant shifts to right side of patient. Small intestine is folded in upper abdomen and root of mesentery is held between two graspers, at ileo-cecal and duodeno-jejunal junction in ‘Chinese Fan’ pattern [Figure 7a]. Thus, lifting ileo-colic pedicle, dissection is started from medial to lateral [Figure 7b].[7] Care is taken to avoid injury to duodenum, right ureter and gonadal vessels. Lateral attachments of right colon are divided [Figure 7c] and dissection is done till hepatic flexure [Figure 7d]. Right sided and transverse colonic pedicles i.e. ileo-colic, right colic and middle colic pedicles are not divided inside abdomen as this is done easily through midline mini laparotomy incision, close to colonic wall. This is important for pouch lengthening, so ileocolic artery may be divided [Figure 8].[8]

Figure 7

(a) Retracting root of mesentery in ‘Chinese Fan pattern’ holding Ileocolic pedicle (b) Medial to lateral dissection exposing second part of duodenum (c) Cutting lateral attachments of right colon (d) Complete dissection of right colon till hepatic flexure

Figure 8

Division of right colonic vessels (Black arrow) close to colonic wall to preserve marginal artery. If ileocolic artery needs to be divided (Red arrow) to relieve tension on pouch- blood supply to pocuh from middle colic artery is preserved

Midline vertical 6 to 7 cm incision is kept skirting around umbilicus and entire small intestine is delivered out of wound to examine for any injury [Figure 9A]. Then small intestine is placed inside and colon is taken out with mesocolon. Mesocolon is divided near colon with help of Ligasure device. Vessels are sealed and ligated with silk ligature at required places i.e. named major pedicles like middle colic and ileo-colic. Specimen is removed and cut section is examined for any suspicious area of malignancy [Figure 9b]. Pouch of terminal ileum is created 15cm long by firing two linear GIA 80mm staplers [Figure 9c].[9] Haemostasis is secured inside pouch at stapler line and pouch is flushed with saline. Anvil of EEA no.28 stapler is fixed to distal end of pouch [Figure 9d]. Ileostomy site is marked with cautery at this stage and small feeding tube is placed across mesenteric window for easy identification on re-laparoscopy.

Figure 9

(a) Minilaparotomy incision (b) Removed specimen of total colon with rectum cut open (c) Applying linear GIA 80 stapler to create ileal pouch (d) Anvil of EEA stapler fixed at the end of ileal pouch

Re-laparoscopy is done with help of disk device [Figure 10a]. Per rectally EEA stapler gun is inserted and anvil is fixed to its head [Figure 10b]. Pouch tension is judged and if required pouch lengthening manoeuvres are done to decrease tension on pouch. Anterior stapler line is kept anterior [Figure 10c] and after confirming this, stapler is fired and doughnuts are checked for adequacy. Pouch is checked for leaks with insufflating air in pouch while pelvis is filled with saline. After confirming hemostasis and instrument count one large bore drain is inserted in pelvis through RIF port. Loop ileostomy is created in single layer with absorbable stitches in RIF [Figure 10d]. Abdomen is closed in layers.

Figure 10

(a) Relaparoscopy with help of disk device (b) Attaching anvil to EEA stapler (c) Orienting pouch before firing stapler (d) Final appearance of abdomen at completion of surgery

POST OPERATIVE CARE

Patient is given injectable antibiotics such as cefoperazone and metronidazole postoperatively. Ryle's tube is removed when bowel sounds are present and output is low, usually on postoperative day one. On the second postoperative day, clear liquid diet is started, and bladder catheter is removed on fifth post operative day. Diet is advanced as tolerated. Low molecular weight heparin is stopped when patient is ambulatory, usually on forth or fifth post operative day. Patient is observed for any signs of intestinal obstruction or sepsis. The patient is discharged from the hospital when he/she has healthy well functioning ileostomy, can tolerate a regular diet and have adequate pain control with oral analgesics. Sutures are removed on seventh post operative day if no wound infection is present.