Mesenteric lengthening plasty with multiple vascular divisions to perform ileoanal anastomosis and J pouch reservoir

Total coloproctectomy with ileal pouch-anal anastomosis is the operation of choice for both ulcerative colitis and familial adenomatous polyposis. The objective of this film is to demonstrate the benefits of mesenteric lengthening using vascular divisions in order to perform an ileoanal anastomosis after a total coloproctectomy.

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Mesenteric lengthening plasty with multiple vascular divisions to perform ileoanal anastomosis and J pouch reservoir

Authors

J Leroy, J Marescaux

Abstract

Total coloproctectomy with ileal pouch-anal anastomosis is the operation of choice for both ulcerative colitis and familial adenomatous polyposis. The objective of this film is to demonstrate the benefits of mesenteric lengthening using vascular divisions in order to perform an ileoanal anastomosis after a total coloproctectomy.

Classification

tips and tricks

Keywords

Mesenteric lengthening plasty, multiple vascular divisions, ileoanal anastomosis, J pouch reservoir

Media type

Surgical video

Duration

07'36''

Publication

2010-06

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E-publication

WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2959.htm

Mesenteric lengthening plasty with multiple vascular divisions to perform ileoanal anastomosis and J pouch reservoir

1. Introduction 00'07''

The objective of this film is to demonstrate the benefits of mesenteric lengthening using vascular divisions in order to perform an ileoanal anastomosis after a total coloproctectomy.The first operating step is to preserve the right colon’s marginal vascular arch. Our operative strategy is to divide the superior mesenteric vessels and potentially the right ileocolic branches (among which, the right accessory branches) in order to obtain sufficient length and preserve vascularization. Here we show the case of a young patient presenting with an ulcerative colitis in which the vascular arch is preserved. And this procedure is all the easier as we can use instruments such as the 5mm Ligasure® or Ligasure Advance® or ultrasonic scissors.

2. Division of colonic vascular branches 01'14''

The vascular branches originating from the vascular arch and running towards the colon are simply divided. The vascular arch is preserved not only on the arterial plane, but also on the venous plane. Dissection in contact to the colon remains possible since our case is not oncologically related. Here we are dealing with an inflammatory or a benign disease. Division is carried out meticulously and precisely, as much in contact to the colonic wall as possible.

3. Colon dissection 01'59''

The colon is then mobilized on its posterior surface starting with the ileocaecum and progressing towards the left colon and the rectum. Here the division of the lateral attachments is nicely performed using the Ligasure Advance® device with monopolar and bipolar currents for the sealing of tissues.

4. Dissection of transverse colon and hepatic flexure 02'27''

The procedure is then continued towards the transverse colon and on to the hepatic flexure as can be seen here using a medial approach. The objective is to complete the freeing of the network of marginal arteries, which can be perfectly seen here by transparency. Caution must be exercised to well preserve all the vessels in order to have a network of marginal arteries in perfect quality as it will be decisive in allowing for the future mesenteric lengthening.

5. Mesenteric division 03'12''

The terminal portion of the small bowel is identified at the level of its junction with the caecum and the division of the meso is continued still staying in contact to the colonic, then ileal wall. The objective is to perform a single division of the vascular branches originating from the network of marginal arteries, which should be preserved and more especially so on the small bowel’s terminal portion. Once the mesentery has been freed from the small bowel’s terminal portion, it is ready for division after controlling its perfect vascularization and after initiating the mobilization of the posterior aspect of the mesentery. Such a mobilization may be continued until the duodenum and here the freeing of the posterior surface of the mesentery is demonstrated anteriorly to the duodenum. The terminal small bowel still remains to be divided. The division may be performed at this time in the procedure. The benefit is to well separate the colon from the terminal small bowel. Once the entire colon and rectum have been mobilized, the anastomosis can be carried out.

6. Division of the superior mesenteric vessels 04'56''

At this moment, the mesentery, and more specifically the superior mesenteric vessels will be divided at the level of the trunk and sufficiently away from the network of marginal arteries, which will be preserved. Whereas it was impossible to lower the last bowel loop, it becomes clear that a few centimeters will be gained thanks to this vascular division. As a result, these few centimeters will allow for the lowering of the small bowel without any difficulty. This approach has made it possible for some authors to envisage tension-free anastomoses without any protective stoma.

7. Creation of J-pouch reservoir 05'47''

In this case, the 18cm long J-pouch reservoir will be performed entirely through laparoscopy by fixing the two legs of the terminal small bowel that will be brought together transanally. The absence of twists should be controlled. It becomes clear that the reservoir reaches the anus without any difficulty, achieving a perfect vascularization. The reservoir is then prepared to be fixed to the pectinate line using absorbable monofilament stitches. These will be cardinal stitches first; then between each cardinal stitch, additional stitches will be placed extramucosally on the digestive anastomosis. Full stitches will be placed on the anal canal. The procedure needs to be completed by the control of the reservoir and of the sphincter’s quality. Protection is always achieved by an ileostomy that should be performed about 30cm away from the ileoanal anastomotic area. Consequently, the reservoir’s extremity can be identified in order to prevent any twist and differentiate the proximal from the distal extremity under laparoscopic control, then through a direct approach.