Laparoscopic treatment of an ulcerative colitis after medical failure: total coloproctectomy with ileoanal anastomosis

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摘要

The objective of this film is to demonstrate a laparoscopic coloproctectomy technique for the treatment of an invalidating ulcerative colitis evolving over several years and resisting to the different medical treatments.

關鍵字

Laparoscopy, ulcerative colitis, medical failure, total coloproctectomy, ileoanal anastomosis

媒體類型

期間

21'52''

刊物

2011-03

普通的

最愛

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副標題

數位出版

WeBSurg.com, Mar 2011;11(03).
URL: http://www.websurg.com/doi-vd01en3206.htm

Laparoscopic treatment of an ulcerative colitis after medical failure: total coloproctectomy with ileoanal anastomosis

1. Introduction 00'21''

2. Patient position 00'37''

The patient is placed in a reverse Trendelenburg position, with the surgeon standing between the patient’s legs. The hepatic flexure of the colon is first exposed. The omentum has been retracted towards the cranial portion of the abdomen, above the transverse colon.

3. Exposure of transverse mesocolon and start of colonic dissection 00'55''

The root of the transverse mesocolon is exposed. Division is initiated as close to the colon as possible in order to preserve the entire network of marginal arteries. This maneuver may be very useful should the terminal portion of the small bowel need to be lengthened. Dissection is continued until the ileocaecal junction. The lateral and posterior attachments of the caecum are then freed while identifying the terminal small bowel and the ureter if necessary. The ureter will be preserved by staying sufficiently in contact to the small bowel and to the colon, and by exerting an anterior traction upon them.

4. Small bowel division 01'48''

The small bowel is divided here as the Endo-GIA linear stapler, white cartridge, is fired.

5. Right colon mobilization 01'56''

The right colon is then further mobilized by dividing the lateral attachments at the level of the parietocolic gutter and by dividing also the few inflammatory adhesions —sequels of the repeated attacks of ulcerative colitis. The 5mm Ligasure Blunt Tip® device is very useful in this type of division as it allows for a perfect hemostasis irrespective of the operator’s experience. One must wait for the division signal to activate the blade that will divide the sealed tissues.

6. Greater omentum dissection 02'42''

The greater omentum is detached here from the right transverse colon. The division of the transverse mesocolon is carried on by exposing the root of the transverse mesocolon, staying as close to the colon as possible since there are no carcinologic problems. In this case, the disease is strictly inflammatory without any signs of cancer.

7. Division of colica media artery 03'15''

Division is carried on from right to left. Here, the division of the branches of the colica media artery can be seen. The lesser sac is opened using a right lateral approach. The greater omentum then is detached from the transverse colon by moving above it. The 5mm Ligasure Blunt Tip® device is a very useful instrument that makes it possible to substantially shorten the operative time. The space anterior to the duodenojejunal flexure is progressively reached, as well as the left and medial branches of the colica media artery. These branches are divided always staying in contact to the transverse colon. Deep down, the stomach and the lesser sac are well visible. No inflammatory adhesions can be seen at this level. The splenic flexure of the colon is then progressively reached. The division of the mesocolon is carried on staying as close as possible to the colon in order to avoid pancreatic lesions —the pancreas being situated posterior to the splenic flexure. This is performed using a medial approach, the surgeon still standing between the patient’s legs.

8. Mobilization of splenic flexure and descending colon 05'23''

The freeing of the lateral attachments of the left colon may be started at the junction between the descending colon and the sigmoid colon. The objective is to completely mobilize the descending colon and the splenic flexure before changing position. The surgeon now stands to the patient’s right as for sigmoidectomy or rectal surgery.

9. Sigmoid colon dissection 05'45''

The sigmoid colon is well exposed and once again, it is unnecessary to divide the inferior mesenteric artery as well as the vein close to the aortic axis. This is beneficial in that it allows for a division away from the nerve plexuses and from the ureter all the more so as the sigmoid colon has been previously perfectly mobilized laterally. The sigmoid mesocolon and the descending mesocolon are completely divided until the area that has been initially divided to the right is reached at the level of the right colon.

10. Rectal dissection 06'34''

The rectum will now be dissected. The type of dissection will be different from the one used in cancer, in contact to the sacrum. The dissection is carried out in contact to the rectal wall in order to preserve the nerve plexuses as much as possible. This is done in order to avoid too important a cavity where the small bowel would fall over and therefore result in a functional impairment. Here again, thanks to the 5mm Ligasure® device, the dissection can be pursued progressively staying on the posterior aspect of the rectum. Division is achieved in the mesorectum to get closer to the distal rectum and to the sacrococcygeal region, which may be accessed without any risk for the plexuses staying in contact to the sacrum. The rectouterine (Douglas’) pouch is opened anteriorly in this female patient, who has had a previous hysterectomy. Dissection is continued always staying in contact to the rectal wall in order to preserve anterior organs and their innervation. Here, one may observe that the rectal wall can be freed without any difficulty. Inflammatory adhesions are indeed very small. Thanks to traction and counter-traction maneuvers, and to divisions using the Ligasure® device, the pelvic floor is progressively reached staying always in contact to the rectal wall. This maneuver is quite sufficient as this procedure does not consist in a resection for cancer in rectal cancer patients.

11. Division of distal rectum 09'07''

Once the pelvic floor has been reached, once the distal rectum has been adequately exposed using a retractor introduced through a suprapubic port, and once the anal canal has been previously identified, the distal rectum is divided. To do so, a linear stapler is used to allow for the distal rectum division as caudally as possible and as close to the pelvic floor as possible. This retractor may be introduced through a suprapubic port. Traction exerted helps to reduce the rectal stump and the portion situated above the anal canal. Hence a minimal mucosectomy will be facilitated as soon as the rectum is totally divided and the transanal approach is initiated.

12. Transanal approach 10'10''

The transanal approach may allow for the colon’s extraction. The colon may also be extracted through an abdominal route at the level of the ileostomy, as performed in this patient. Here, the extraction is achieved suprapubically to avoid contamination and too much pain. The abdominal wall has been protected by a plastic drape. The volume to be extracted is fairly important.

13. J pouch preparation 11'09''

The pouch now remains to be prepared. The entire small bowel must be first controlled to verify that it is not twisted, and the area to be lowered at the level of the anal canal must also be defined. As can be seen here, the surgeon evaluates the lowering possibilities and the potential need for lengthening plasties at the level of the meso. Preservation of the network of marginal vessels renders this step of the procedure easier, thus allowing to divide the mesenteric vascular axis, if need be. Both tails of the J-pouch approximately measure 15cm, even a bit more. They are prepared intra-abdominally, as can be seen in these pictures. The extracorporeal knot makes this operative step easier. The assistant now ties the extracorporeal knot as performed in open surgery, namely by placing very simple knots. Once both tails have been connected together, the apex of the pouch is identified and pulled through a suprapubic incision, thus allowing to exteriorize the small bowel and to find out the limits of the lowering. As can be seen here, the lowering exceeds the pubis symphysis from 7 to 8cm. This seems to indicate that the anastomosis will be easily placed. This is only for a test. The J-pouch is achieved here by introducing the 60mm Endo-GIA linear stapler at the level of its apex so as to carry out the anastomosis. Three firings will be needed before partially closing this extremity using quite a loose figure-of-eight stitch. It will be used as a landmark to pull the apex of the pouch transanally. This is carried out after having reintroduced the pouch in the abdominal cavity.

14. Running suture on staple line 14'20''

A complementary monofilament Maxon® or PDS running suture is placed here in order to cover the stapling area, thus allowing for an enhanced security in the stapling area on its anterior surface. The pouch is perfectly vascularized, and the running suture allows to completely cover the stapling area, as intended. The pouch is reintroduced in the abdominal cavity. Its posterior portion is controlled on the mesenteric side. The abdominal wall’s patency is perfectly ensured by twisting this plastic wound protector, which will be clamped. The anal canal must be prepared now. A mucosectomy has been carried out. The pouch is positioned before dealing with the perineum. The mucosectomy is completed until the stapling area, preserving the seromuscular plane in order to carry out the anastomosis in a seromuscular sheath. The stapling area will be excised, as can be seen in these pictures, thus allowing to open the pelvic cavity. Now the thread that had been previously lowered can be identified. It will help to easily bring back the pouch at the level of the anal canal without the need for any traction, as can be seen here. If in doubt, the absence of pouch rotation must be controlled.

15. Ileoanal anastomosis 16'50''

The anastomosis is carried out manually using separate monofilament stitches placed in the four cardinal directions, this is, in a 6 o’clock, 12 o’clock, 9 o’clock and 3 o’clock position, thus allowing for an appropriate exposure of the anal canal before finalizing the anastomosis. One or two monofilament stitches will be placed between each cardinal point until properly completing the anastomosis. The Lone Star™ retractor proves efficacious here, as it allows for an almost atraumatic exposure of the anal canal and especially for a perfect access to this area until the anastomosis is finished stitch by stitch, as it had been initiated, using absorbable PDS 3/0 monofilament threads. Once this has been achieved, the retractor is removed. A digital rectal examination is carried out. It allows to verify that the anastomosis is perfectly compliant and the pouch is large.

16. Mesenteric defect closure 18'23''

A last control of the pouch and of the abdominal cavity is performed. The mesenteric defect is closed in order to avoid any potential internal occlusion, as this may occur even in the absence of malrotation. Either staples or a monofilament running suture can be used for this purpose, thus allowing to close the mesenteric defect on the right portion of the abdomen.

17. Ileostomy 19'03''

In this patient under corticosteroid therapy and strong immunotherapy, the anastomosis must be protected. This is why a segment of the small bowel is searched for, some 30cm away from the anastomosis, in order to carry out an ileostomy at the left iliac fossa in a consistent fashion. The adipose tissue is excised in order to fashion a subcutaneous tunnel. The segment of the small bowel previously identified is brought back through the aponeurosis incision. A diverting ileostomy is performed as we do routinely. It is maintained in place for some two months due to corticosteroid therapy and immunotherapy issues, and given the high risk of dehiscence in this immunosuppressive patient. Before opening the ileostomy, all port sites are closed, namely the suprapubic incision through which the small bowel had been exteriorized. The peritoneum is closed using a purse-string. This maneuver is completed by carrying out an ileostomy with eversion of the ileostomy margins.

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