Download Laparoscopic restorative proctocolectomy for ulcerative

Laparoscopic restorative proctocolectomy for ulcerative colitis or familial
adenomatous polyposis
Elsa B. Valsdottir, MD
Department of General Surgery
University Hospital of Iceland
Hringbraut
101 Reykjavik
Iceland
Phone +354 543 1000
Fax + 354 543 1016
E-mail: [email protected]
Introduction
Restorative proctocolectomy with ileal J pouch anal anastomosis (IPAA) with
Brooke ileostomy is a technically challenging procedure, whether it is performed
open or laparoscopically. In the latter case, it is an advanced procedure and
should only be offered to selected patients by surgeons who have extensive
experience with conventional surgery for inflammatory bowel diseases and
advanced laparoscopic colorectal surgery. The benefits of laparoscopic
restorative proctocolectomy have been debated. In fact, as early as in 1992
Wexner et al. reported no immediately recognizable benefits in patients
undergoing laparoscopic total colectomy1. A Cochrane systematic review
including 253 patients undergoing laparoscopic restorative proctocolectomy from
11 studies reported no significant differences in postoperative outcome measures
when compared to conventional surgery in 20092. However, a more recent
review from 2014 demonstrates both short and long term benefits3. Technically
speaking laparoscopic restorative proctocolectomy has been described as
laparoscopic assisted in most case series and also as hand assisted to a lesser
extent.
Indications
Laparoscopic proctocolectomy with IPAA and Brooke ileostomy should be
considered as an option to its conventional counterpart with the indications that
currently apply to elective open surgery. All reasonable efforts should be made to
ascertain whether the patient understands the concept and likelihood of
conversion to conventional surgery becoming necessary. Advantages and
disadvantages of surgical treatment options must be discussed extensively with
the patient. Conservative estimates of pouch failure rates must be shared with
the patient and alternative treatment plans discussed in the event the pouch
would have to be excised in the follow-up period following index surgery4.
Permanent end ileostomy and continent ileostomy are among the options to be
discussed. Patients must attend ostomy care classes before index surgery.
Appropriate timing for discontinuation of pre-operative medications should also
be evaluated for patients with ulcerative colitis. Conservative estimates of the
possible impact of pre-operative steroids and/or biologics upon postoperative
septic complications should be included when counseling ulcerative colitis
patients. The patient should understand the material facts, possible risks and
complications of the planned surgery before the patient signs an informed
consent.
Preoperative care
A thorough history and physical exam are essential. Chest x-ray and EKG should
be performed in patients over the age of 50. Preoperative workup includes a
complete blood count, chemistries, coagulation profile and a type and screen. A
full colonoscopy is mandatory, with biopsy of any suspect leasions. A
preoperative evaluation of the anal sphincters with manometry and ultrasound is
appropriate particularly in older female patients. The bowel should be prepped
orally as per each institution’s protocol. It is helpful to have a stoma nurse mark
the planned stoma site to ensure optimal placement.
OR set-up
The patient should be identified with an appropriate time out prior to the induction
of general anaesthesia with endo-tracheal intubation. Perioperatively intravenous
antibiotics should be administered as per each institution’s protocol. The
operating table needs to be capable of side tilt as well as extreme Trendelenburg
and reverse Trendelenburg positioning. A Foley catheter and orogastric tube
should be inserted. The patient is supine on the operating table with the lower
limbs either in modified stirrups or spread. Sequential compression devices are
applied to the legs. Both arms should be tucked. The patient should be securely
strapped to the table at the chest. The abdomen and perineum should be
prepped and draped sterile. All equipment should be placed on the patient’s right
side in clear view of the surgeon, who stands on the patient’s left side for most of
the case. Mobile monitors need to be on both sides of the patient. One assistant
is needed to operate the camera and a second assistant to aid with retraction,
especially during the pelvic dissection.
Surgical technique
Following is a description of a clockwise sequence, broken down into anatomical
sections, and the steps of each section identified. The major difference between
this procedure and standard segmental resections is that the vessels are divided
close to the colon or where it is most convenient, not at their origin, since these
are oncologic concerns and thereby no need to remove all lymph bearing tissue
for each segment. The instruments used are a blunt 5 mm bowel grasper in the
surgeon’s left hand and a 5 mm electrosurgical vessel-sealing device in the
surgeon’s right hand. The latter may be used for both dissecting and cauterising.
If the surgeon prefers an ultrasonic device, a vascular stapler should be used for
the vascular pedicles. Additional instruments are scissors, long grapers, powered
suction device, endoscopic staplers and a 30-degree scope (10 mm in diameter).
A pre-tied loop or clip applier should always be available to control bleeding not
controlled by the energy device. It is preferable to have a smoke filter attacheed
to one of the ports to allow for safe venting of smoke.
Choice of mode of access (open Hasson or Verres needle) to the peritoneal
cavity should be based on the surgeon’s experience and preference.
Port placement:
Nr. 1:10 mm port supraumbilically
Nr. 2: 12 mm port on the right, at the planned stoma site
Nr. 3: 5 mm port in right fossa
Nr. 4: 12 mm port suprapubically
Nr. 5: 5 mm port in left fossa
Step 1: Ileocolic vessels.
While placing the ports, the surgeon and assistant stand on opposite sides of the
patient. They then both move the patient’s left side and the right side monitor is
placed below the patient’s shoulder. The camera is placed at the nr. 1 port and
the surgeon uses ports nr. 4 and 5. The table is turned into a moderate left tilt as
well as into a slight Trendelenburg position. The peritoneal surfaces and liver are
inspected for unexpected tumor growth. The omentum and small bowel are
gently displaced into the left upper quadrant. The ileocolic vessels are identified
by gentle traction applied to the mesentery of the cecum and the superior
mesenteric vein (SMV) and duodenum are located. A window beneath the
ileocolic vessels is opened incising the peritoneum close to the origin of the
vessels. This gives access to the avascular space underneath the colonic
mesentery, where the colon can be pealed off the retroperitoneum. The ileocolic
vessels are gently dissected out and then divided as close to the colon as is
comfortable.
Step 2: Medial mobilization
The dissection continues medially along the mesentery from the point where the
ileocolic vessels were divided and goes cephalad. The right ureter is identified
and the duodenum kept in clear view. If present, the right colic vessels are
divided. For now, the dissection ends at the origin of the Henle’s gastrocolic trunk
from the SMV.
Step 3: Opening the lesser sac
The table is leveled from the Trendelenburg position but kept in a moderate left
tilt; the gastrocolic ligament (omentum) is grasped with the left hand and
retracted caudally as well as up towards the abdominal wall, opened using the
energy device and the lesser sac entered. The division of the gastrocolic
ligament is performed in a medial to lateral direction towards the heptic flexure
caudal to the right gastroepiploic vessels.
Step 4: The hepatic flexure
The hepatic flexure is mobilized in a medial to lateral direction, the lateral
peritoneal reflection of the ascending colon is divided along the white line of Toldt
in a caudal to rostral direction and the mesentery of the ascending colon is
mobilized off the retroperitoneum.
Step 5: Terminal ileum
The surgeon swiches the instruments so the grasper is in port nr. 5 and the
energy device in port nr. 4. The pole of the coecum and the terminal ileum are
mobilized from the lateral side and the dissection continued until it meets the
dissection from the medial side. The final attachements of the ascending colon
are taken down, so the right colon is fully mobilized.
Step 6: Middle colic vessels
The surgeon and assistant move to the patient´s right side, the left side monitor
is placed at the patient’s shoulder. The camera remains in port nr. 1 and the
surgeon uses port nr. 2 for the grasper and nr. 3 for the energy device. The table
is tilted to the right, so the right colon falls out of the way, and in reverse
Trendelnburg position. The transverse colon is gently elevated off the duodenum
to identify the middle colic vessels. It is important to recognize the anatomic
location of the superior mesenteric vein as well as the gastrocolic trunk of Henle.
These vessels are short and excessive traction can lead to profuse bleeding at
the inferior border of the pancreas. The branches of the middle colic vessel are
divided close to the colon while the transverse mesentery is held up (also know
as “Ole maneuver”). The mesentry is devided towards the splenic flexure.
Step 7: Splenic flexure
Division of the greater omentum is continued towards the patient’s left by
grasping the gastrocolic ligament, thus fully opening the lesser sac, always
avoiding traction on the spleen. The splenic flexure is mobilized laterally by
retracting the colon gently medially and dividing the lateral attachments as well
as peeling the colon off the Gerotas fascia, carefully avoiding the tail of the
pancreas.
Step 8: Repositioning
The patient is now placed in steep Trendelenburg position, keeping the right tilt.
The left sided monitor is moved towards the patient’s hip. The camera is moved
to port nr. 2 and the surgeon uses ports nr. 1 and 3. The already mobilized right
colon, along with the small bowel and omentum, are swept out of the pelvis and
placed in the right upper quadrant.
Step 9: Inferior mesenteric vessels
The medial mobilization of the descending colon starts by opening the retro
peritoneum at the sacral promontorium, getting underneath the mesentery of the
colon and lifting it up, making sure that the left ureter and gonadal vessels stay
down. The inferior mesenteric artery is identified and its branches dissected out,
preserving the hypogastric nerves. The vessel braches are divided individually
near the colon. The opening of the retropertitoneum is continued cephalad until
the inferior mesenteric vein is located. This is dissected out and dived. The
remaining mesentery is lifted off the retroperitoneum and divided.
Step 10: Lateral mobilization
Following the peritoneal reflection of the white line of Toldt while retracting the
colon medially connects the dissection from above and medial to complete the
mobilization of the colon. It is important to by mindful of the lay of the ureter again
from this side, especially at the pelvic brim.
Step 11: Rectal mobilization
It is neccesary to have a second assistant to aid with the rectal mobilization,
using ports nr. 4 and 5 for retraction. In women, a bulky uterus can be lifted up
with a stich through the fundus and the abdominal wall. First, the peritoneum is
opened down both pararectal sulci and then anteriorly at the peritoneal reflexion
(bottom of the Douglas pouch in women, rectovesical excavation in men). It is
easiest and safest to stay outside the mesorectal fascia, or in the so-called “Holy
Plane”, since this is avascular and allows for sparing of the branches of the
inferior hypogastric nerve plexus. The dissection is performed with a combination
of blunt dissection and cautery. The surgeon places traction on the rectum while
the assistant retracts the tissue along the pelvis walls laterally and anteriorly,
thus always maintaining a three-way retraction. The middle rectal artery can be
taken using the energy source instrument used before. The rectum is mobilized
anteriorly well below the level of the seminal vesicles in men and in women, well
below the cervix. Laterally and posteriorly, the mobilization is carried down to the
levator muscles. The junction of the rectum and the anus is recognized where the
mesorectum ends and confirmed by digital examination of the rectum.
Step 12: Transecting the rectum
An endoscopic stapler is brough in through port nr. 4 and the rectum transected
where it meets the anus. Usually, at least two cartridges are needed, since the
longer staplers can not be easely applied this low in the pelvis. The cut end is
grasped with a locking grasper and the abdomen desufflated.
Step 13: Extraction of specimen
In thin patients, extraction of specimen through the stoma site is an option. The
stoma site can be opened in a usual fashion. The stapled oral end of the colon is
brought to the stoma site and the specimen delivered. Alternatively, a short
Pfannenstiel incision (4-5cm) is performed, a wound protector placed and the
specimen retrieved.
Step 14: Creation of pouch
The terminal ileum is transected with a linear stapler. A 15 cm long pouch is
created extracorporeally in the usual fashion. The end of the pouch should reach
at least 5 cm below the symphisis pubis to ensure tension-free anastomosis. The
anvil of the circular stapler is placed in the enterotomy and secured with a purse
string suture. The pouch is returned to the abdomen. If the specimen was
removed through a Pfannensteel incision, the wound protector is removed, the
fascia closed and the abdomen re-insufflated. If the specimen was removed
through the stoma site, the wound protector is wrapped around it self and
secured with towel clips so the abdomen can be re-insufflated.
Step 15: Anastomosis
A second assistant goes between the legs and irrigates the rectal stump with
iodine. If the staple line shows no leak, a circular stapler is placed through the
anus and the spike brought out through the anal wall just anterior to the staple
line. The anvil in connected to the spike and the stapler closed, ensuring that no
extra tissue is caught. Once proper orientation of the pouch and lack of tension is
confirmed, the stapler is fired. The tissue rings from the stapler are examined to
make sure they are both full circle and full thickness. The anastomosis is not
tested for leakage, since insertion of an instrument to insufflate may itself
damage the very low ileo-anal anastomosis. Final inspection for adequate
hemostasis in all four quadrants is performed. A drain is placed in the pelvis and
brought out through port nr. 3.
Step 18: Creation of Brooke ileostomy
The small bowel is traced back from the pouch (at least 20 cm) to find a
convenient loop for the stoma. At that loop, the small bowel is grasped with a
locking, non-traumatic grasper, noting the orientation of the bowel with regards to
the aferent and efferent limbs. The abdomen is desufflated and the chosen bowel
loop grasped with a babcock and brought out. A pin is placed under the bowel
loop, all trocars removed and the fascia at the 10 and 12 mm ports closed. All
skin incisions are closed and dressings applied. A loop ileostomy is created,
everting the cut edges and making sure that the aferent limb is cephalad.
Postoperative care
If a naso- or orogastric tube is used intraoperatively, this should be removed at
the end of the procedure. The patient is encouraged to ambulate on the day of
the procedure, since early mobilization is imperative to prevent complications like
atelectasis, pneumonia or vein thrombosis. A liquid diet should be started on post
operative day 1 if there are no clinical signs of ileus. Usually oral pain
medications are tolerated on POD#1. The foley catheter should also be removed
on POD#1 unless there are clinical signs of hypovolemia. Most patients are
ready for discharge from the hospital on POD#3-4. Follow up should be at 2 and
6 weeks and after that according to each institution’s protocol. Revision of the
temporary stoma can usually be performed laparoscopically after 3 months, once
the integrity of the pouch has been verifried by contrast enema and flexible
endoscopy.
References
1. Wexner SD, Johansen OB, Nogueras JJ, et al. Laparoscopic total abdominal
colectomy. A prospective trial. Dis Colon Rectum 1992;35:651-655
2. Ahmed Ali U, Keus F, Heikens JT, Bemelman WA, Berdah SV, Gooszen HG,
van Laarhoven CJHM. Open versus laparoscopic (assisted) ileo pouch anal
anastomosis for ulcerative colitis and familial adenomatous polyposis. Cochrane
Database Syst Rev 2009;21;(1): CD006267
3. Buskens CJ, Sahami S, Tanis PJ, Bemelman Wa. The potential benefits and
disadvantages of laparoscopic surgery for ulcerative colitis: A review of current
evidence. Best Pract Res Clin Gastroenterol 2014;28:19-27
4. Wasmuth HH, Myrvold HE, Bengtsson J, Hultén L. Conversion of a failed
pouch to a continent ileostomy: a controversy. Colorectal Dis. 2011;13(1):2-5