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Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis.

Jani K, Shah A - J Minim Access Surg (2015 Jul-Sep)

Bottom Line: All surgeries were successfully completed laparoscopically without need for conversion.Oral diet was resumed at a mean of 3.4 days (range: 1.5-6 days) and the mean hospital stay was 8.2 days (range: 4-26 days).Overall morbidity rate was 16.2%; re-operation rate was 9.7% while mortality was nil.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgical Gastroenterology and Minimal Access Surgery, SIGMA, Baroda, Gujarat, India.

ABSTRACT

Aim: The aim was to study the feasibility of the laparoscopic approach in the management of ulcerative colitis, to assess the functional results at 1-year and to review of literature on the topic.

Materials and methods: All patients presenting for surgical management of histopathologically proven ulcerative colitis during the study period were included in the study. All patients presenting in a non-emergency setting were offered a two-stage procedure (Group A). The first-stage consisted of laparoscopic total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) with a diverting split end ileostomy. Ileostomy was closed in the second stage. For patients presenting in acute setting (Group B), the first-stage consisted of laparoscopic TPC with end ileostomy followed by IPAA with diverting split end ileostomy in the second-stage and finally ileostomy closure in the third-stage. The technique is described.

Results: A total of 31 cases underwent laparoscopic TPC-IPAA, of which 28 belonged to Group A and 3 were included in Group B. All surgeries were successfully completed laparoscopically without need for conversion. The average operating time was 375 min in Group A (range: 270-500 min) and 390 min in Group B (range: 250-480 min). Oral diet was resumed at a mean of 3.4 days (range: 1.5-6 days) and the mean hospital stay was 8.2 days (range: 4-26 days). Overall morbidity rate was 16.2%; re-operation rate was 9.7% while mortality was nil.

Conclusions: Laparoscopic TPC-IPAA is feasible in acute as well as non-acute setting in patients needing surgical management of ulcerative colitis.

No MeSH data available.


Related in: MedlinePlus

Pouch anal anastomosis completed
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Figure 6: Pouch anal anastomosis completed

Mentions: The ports placement is depicted in Figure 1a–c are 10 mm ports used for telescope for the different phases of the operation. Port C is also used for deploying the stapler for ano-rectal transaction. D and E are 5 mm ports used for working instruments and for retraction. For the first phase, the operating surgeon stands on the left of the patient; the camera surgeon between the patients legs with the telescope placed through port B, and an assistant surgeon on the right side of the operating surgeon. The monitor is placed near the right shoulder of the patient, facing the operating surgeon. The bowel is divided near the ileocecal junction, and the root of the mesentery is divided almost up to the duodenojejunal flexure to lengthen the mesentery. Dissection is carried out using ultracision. In patients with thick mesentery and mesocolon, a vessel-sealing device may be more effective. The operation table is tilted right side up and head low for the initial part of the dissection. The dissection is begun by mobilising the cecum (a) and appendix (b), lifting up the ascending colon from the retroperitoneum and dividing its lateral attachments [Figure 2]. For the dissection of the hepatic flexure and the right half of the transverse colon, the table is tilted head up. Port A [Figure 1] is the camera port while ports D and C are the working ports. The hepatic flexure and the right half of the transverse colon are mobilised, and its mesocolon divided [Figure 3, a: Hepatic flexure, b: Liver, c: Second part of the duodenum]. Using For the second phase, the operating surgeon stands on the right side of the patient, the camera surgeon on his left and the assistant remain on the left side of the patient. The monitor is placed near the left thigh of the patient, facing the operating surgeon. The patient is placed in a steep Trendelenburg position. Deep pelvic circumferential dissection of the rectum may be facilitated by the assistant applying cranial pressure externally over the anus. Figure 4 shows the completeness of the pelvic dissection as viewed from the right side; ‘a’ marks the sacrum, ‘b’ the rectum with the mesorectum. The arrows point to the inner dissected margin of the pelvic diaphragm. Transection of the distal rectum/anal canal is carried out using a reticulating stapling device with 4.5 mm staples (green load) [Figure 5]. In female patients, it may be helpful to suspend the uterus to the lower anterior abdominal wall by a sling suture passing through a broad ligament on each side and brought out over the abdominal wall, just above the symphysis pubis. For the third phase, the operating surgeon stands between the legs of the patient, with the camera surgeon on his left, an assistant surgeon on his right and the monitor facing him near the left shoulder of the patient. The patient is tilted head up and left side up for this phase of the surgery. For the last phase, the operating team is oriented as in phase two. A circular piece of skin is excised at the previously marked ileostomy site, which incorporated trocar C, the muscle is split and peritoneum opened. The TPC specimen is extracted through a plastic sheath to protect the wound margins, and the distal end of the ileum is brought out. For surgeries performed in emergency setting, the terminal ileum is fashioned into an ileostomy. For planned surgeries, sufficient length of ileum is brought out to enable construction of 15 cm limbed J-pouch. The apex of the pouch is opened and the anvil of 31 mm circular stapler is inserted and fixed with a purse-string suture. The bowel is replaced into the abdomen, port re-inserted and pneumoperitoneum established. Pouch anal anastomosis is constructed, keeping a check to see that the bowel is not rotated, to prevent torsion of the mesentery [Figure 6]. A pelvic drain is placed; loop of ileum is brought out through the designated opening and ports are closed. A split end ileostomy is constructed with the distal closed end just beneath the peritoneum, to enable easy identification during later ileostomy closure.


Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis.

Jani K, Shah A - J Minim Access Surg (2015 Jul-Sep)

Pouch anal anastomosis completed
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4499922&req=5

Figure 6: Pouch anal anastomosis completed
Mentions: The ports placement is depicted in Figure 1a–c are 10 mm ports used for telescope for the different phases of the operation. Port C is also used for deploying the stapler for ano-rectal transaction. D and E are 5 mm ports used for working instruments and for retraction. For the first phase, the operating surgeon stands on the left of the patient; the camera surgeon between the patients legs with the telescope placed through port B, and an assistant surgeon on the right side of the operating surgeon. The monitor is placed near the right shoulder of the patient, facing the operating surgeon. The bowel is divided near the ileocecal junction, and the root of the mesentery is divided almost up to the duodenojejunal flexure to lengthen the mesentery. Dissection is carried out using ultracision. In patients with thick mesentery and mesocolon, a vessel-sealing device may be more effective. The operation table is tilted right side up and head low for the initial part of the dissection. The dissection is begun by mobilising the cecum (a) and appendix (b), lifting up the ascending colon from the retroperitoneum and dividing its lateral attachments [Figure 2]. For the dissection of the hepatic flexure and the right half of the transverse colon, the table is tilted head up. Port A [Figure 1] is the camera port while ports D and C are the working ports. The hepatic flexure and the right half of the transverse colon are mobilised, and its mesocolon divided [Figure 3, a: Hepatic flexure, b: Liver, c: Second part of the duodenum]. Using For the second phase, the operating surgeon stands on the right side of the patient, the camera surgeon on his left and the assistant remain on the left side of the patient. The monitor is placed near the left thigh of the patient, facing the operating surgeon. The patient is placed in a steep Trendelenburg position. Deep pelvic circumferential dissection of the rectum may be facilitated by the assistant applying cranial pressure externally over the anus. Figure 4 shows the completeness of the pelvic dissection as viewed from the right side; ‘a’ marks the sacrum, ‘b’ the rectum with the mesorectum. The arrows point to the inner dissected margin of the pelvic diaphragm. Transection of the distal rectum/anal canal is carried out using a reticulating stapling device with 4.5 mm staples (green load) [Figure 5]. In female patients, it may be helpful to suspend the uterus to the lower anterior abdominal wall by a sling suture passing through a broad ligament on each side and brought out over the abdominal wall, just above the symphysis pubis. For the third phase, the operating surgeon stands between the legs of the patient, with the camera surgeon on his left, an assistant surgeon on his right and the monitor facing him near the left shoulder of the patient. The patient is tilted head up and left side up for this phase of the surgery. For the last phase, the operating team is oriented as in phase two. A circular piece of skin is excised at the previously marked ileostomy site, which incorporated trocar C, the muscle is split and peritoneum opened. The TPC specimen is extracted through a plastic sheath to protect the wound margins, and the distal end of the ileum is brought out. For surgeries performed in emergency setting, the terminal ileum is fashioned into an ileostomy. For planned surgeries, sufficient length of ileum is brought out to enable construction of 15 cm limbed J-pouch. The apex of the pouch is opened and the anvil of 31 mm circular stapler is inserted and fixed with a purse-string suture. The bowel is replaced into the abdomen, port re-inserted and pneumoperitoneum established. Pouch anal anastomosis is constructed, keeping a check to see that the bowel is not rotated, to prevent torsion of the mesentery [Figure 6]. A pelvic drain is placed; loop of ileum is brought out through the designated opening and ports are closed. A split end ileostomy is constructed with the distal closed end just beneath the peritoneum, to enable easy identification during later ileostomy closure.

Bottom Line: All surgeries were successfully completed laparoscopically without need for conversion.Oral diet was resumed at a mean of 3.4 days (range: 1.5-6 days) and the mean hospital stay was 8.2 days (range: 4-26 days).Overall morbidity rate was 16.2%; re-operation rate was 9.7% while mortality was nil.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgical Gastroenterology and Minimal Access Surgery, SIGMA, Baroda, Gujarat, India.

ABSTRACT

Aim: The aim was to study the feasibility of the laparoscopic approach in the management of ulcerative colitis, to assess the functional results at 1-year and to review of literature on the topic.

Materials and methods: All patients presenting for surgical management of histopathologically proven ulcerative colitis during the study period were included in the study. All patients presenting in a non-emergency setting were offered a two-stage procedure (Group A). The first-stage consisted of laparoscopic total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) with a diverting split end ileostomy. Ileostomy was closed in the second stage. For patients presenting in acute setting (Group B), the first-stage consisted of laparoscopic TPC with end ileostomy followed by IPAA with diverting split end ileostomy in the second-stage and finally ileostomy closure in the third-stage. The technique is described.

Results: A total of 31 cases underwent laparoscopic TPC-IPAA, of which 28 belonged to Group A and 3 were included in Group B. All surgeries were successfully completed laparoscopically without need for conversion. The average operating time was 375 min in Group A (range: 270-500 min) and 390 min in Group B (range: 250-480 min). Oral diet was resumed at a mean of 3.4 days (range: 1.5-6 days) and the mean hospital stay was 8.2 days (range: 4-26 days). Overall morbidity rate was 16.2%; re-operation rate was 9.7% while mortality was nil.

Conclusions: Laparoscopic TPC-IPAA is feasible in acute as well as non-acute setting in patients needing surgical management of ulcerative colitis.

No MeSH data available.


Related in: MedlinePlus