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

Madnani MA, Mistry JH, Soni HN, Shah AJ, Patel KS, Haribhakti SP - J Minim Access Surg (2015 Jul-Sep)

Bottom Line: Laparoscopy benefits these patients with better outcomes in context of cosmesis, pain and early recovery, especially in young patients.Starting from preoperative preparation to post operative care there are wide variations as compared to open surgery.So we present our standardized technique of laparoscopic assisted restorative proctocolectomy and ileal pouch anal anastomosis (IPAA).

View Article: PubMed Central - PubMed

Affiliation: Department of Surgical Gastroenterology, Sterling Hospital, Ahmedabad, Gujarat, India.

ABSTRACT
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).

No MeSH data available.


Related in: MedlinePlus

(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
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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

Mentions: 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.


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

Madnani MA, Mistry JH, Soni HN, Shah AJ, Patel KS, Haribhakti SP - J Minim Access Surg (2015 Jul-Sep)

(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
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4499933&req=5

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
Mentions: 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.

Bottom Line: Laparoscopy benefits these patients with better outcomes in context of cosmesis, pain and early recovery, especially in young patients.Starting from preoperative preparation to post operative care there are wide variations as compared to open surgery.So we present our standardized technique of laparoscopic assisted restorative proctocolectomy and ileal pouch anal anastomosis (IPAA).

View Article: PubMed Central - PubMed

Affiliation: Department of Surgical Gastroenterology, Sterling Hospital, Ahmedabad, Gujarat, India.

ABSTRACT
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).

No MeSH data available.


Related in: MedlinePlus