PREPRINT
jkl keys enabled
593 views

Laparoscopic Total Abdominal Colectomy with Ileorectal Anastomosis

Richard Hodin, MD
Massachusetts General Hospital

Transcription

CHAPTER 1

So today we're operating on a patient who's a 59-year-old man who has a history of what appears to be Crohn's colitis. He has actually a long-standing GI history and was thought to have IBS for many years, but in retrospect it was probably Crohn's colitis, and - recently on a couple of colonoscopies was found to have multifocal dysplasia in at least 2 or even 3 areas of the colon, and these areas could not be excised through the scope, so surgery was recommended as really the only possible or reasonable approach in this setting.

Now interestingly, his rectum has always been spared, both based on colonoscopy and biopsies. He's never had either inflammation or dysplasia in that area, so after much discussion we decided to proceed with a subtotal colectomy or total abdominal colectomy with an ileorectal anastomosis rather than an ileoanal J-pouch operation on him, feeling that his rectum has been healthy and unlikely to be a source of problem for him in the future and this operation would be a much better functional result than the J-pouch surgery.

So our plan is a laparoscopic total abdominal colectomy with ileal J-pouch rectal anastomosis. I generally do a small ileal J-pouch in this setting, which I think helps facilitate the anastomosis and perhaps provides a little bit of extra capacity and reservoir in terms of bowel function. So the key steps of the procedure will be to first gain access the peritoneal cavity with laparoscopy, and I always use open laparoscopy with the Hasson technique.

And then we will get into the peritoneum, inspect the abdominal contents, place our various trocars, and then begin dissection. I use a laparoscopic LigaSure device for this operation and we will mobilize the entire colon off of the retroperitoneum, generally starting on the right side, taking the omentum off of the transverse colon going around to the left side.

And then we will divide the distal sigmoid at the point where we're happy that we're below the area of his disease. We'll do that with an endoscopic stapler and then divide and ligate the mesentery of the colon. Usually I go from the left side back around to the right with the LigaSure.

And then once that's done we will enlarge the infraumbilical port site, bring out the colon, divide at the ileum, make our small J-pouch of the ileum, put it back into the abdomen, and - reinsufflate once we close that infraumbilical site enough to get a laparoscopic seal.

And then we will do our anastomosis using the EEA stapler between the ileal J-pouch and the rectum and then test the anastomosis, and if everything is okay, we'll close.

CHAPTER 2

So, we're going to do this. That'll be our umbo, and then - here's, sort of, pubis. Let's just say - we can make it a little longer there. Something here. One of them can go, actually, here. Usually.

CHAPTER 3

Incision.

Right there. Go ahead.

There it is. Got it?

Mhm.

That looks good.

So let's just - yeah, take a gaze around. This colon is a little bit big, but, whatever.

CHAPTER 4

Hold on. I'm going to just grab the appendix -

It's right there.

- as our sort of apex.

So this is where we want to be, right?

Yep, exactly.

And I'll vent us every once in a while so we can have a nice -

These are little bit extra attachments, I think. Maybe because he's had a bunch of -

Scopes and biopsies?

Yeah, I don't know, with attempted - I don't know. Or it's just a little bit of colitis stuff. Well, but I wonder if we should come up closer to the colon, actually, even though it's - that stuff is - yeah, just go right there and get it. We'll make our way closer to the colon.

If I go like this, you go opposite and kind of push down a little and just sort of see what happens and - See that…

This line?

- that's tending to push around, just push it away, yeah, just to kind of stay - make sure we're close.

That's appendix there, right? So we want to -

You can take some of that stuff now, you know, here.

So then you can go kind of both directions up a little bit. Yeah.

And then the other - from the opening. And I'll go north. Yep. Grab that stuff. Yep. See how we're getting a little closer to colon there?

Yep. Go ahead there.

So that's too far away from the colon, so that's - but anyway, go up north. Get that - yep.

So can you grab the bowel

Sure.

Try it, yep. See what happens if you lift it up and over. You know what I mean? So it kind of lifts over like that. See what I'm saying?

That's where we want to be.

If I go like this, get this in here. That's the - see the plane there?

Yeah. No, I know that -

So I just hold that like that. So I'll kind of go hand over hand. One goes this way, and then I kind of - see underneath there, that sort of - the colon going like that.

Get that up there for you.

Yeah, nice. See if that opens it up more. And then we'll go back, then, and get - what I want to then usually do is now get the - Now come back this way. We have to get the colon off of the duodenum.

Yeah, the duo - we haven't seen duo yet.

Is that duo below you? Yeah.

Should be. It's gotta be, right?

Yeah. That's what I think.

Yeah, right down there.

Yep. Exactly.

So let's - so there's duodenum, for sure. So now let's stay - just kind of get that plane a little.

I can regrab to hold that up.

So it's right there, and then - see what I mean? Because then we want to be here.

Put that in the center, if you can? Yeah. Just getting these attachments, that way - the colon will come.

We should be able to take this, though, right?

I agree.

It's got to be - one of the -

So now - that's holding us up.

So it's coming way off nicely, which is what we want. And I just want to make sure that this continues -

Okay. So now - Let's say we take, now, omentum, and lift it up.

Yep. Exactly.

Right? And let's just go and -

Where's my other hand here?

Okay, so now, lift it up this way, right?

I'm going to go here and get this going. This is where we want to be.

Yeah, it looks better.

Because then we're going to start - getting the omentum off the -

The colon.

Now we should go back up there. Yeah.

Okay, so now - that's lesser sac, right?

That should get you in.

I'll hold it down so we can sort of see where it's going, you see what I'm saying? And I'm going to march along.

Alright, that all goes that way.

Hold on, let me adjust you.

Can we get a little more shift to his right?

Sure.

Just a little bit.

So that's appendix, right? Alright, grab that. Look down, there.

So that's appendix. Here's colon. Can we get through?

You're almost -

You think we're almost through there?

Yeah.

Is that - that is through right there. Yeah, that's through for sure.

You can see the back side of the colon.

So let's just see, if we lift that up - The reason to do that, at least in my experience, is then you can go - then we can follow it. There's colon - wait, hold on a second. So we want to lift up - let's see, can you get your instrument in there?

Yep.

If I lift up like that, then this is - mesentery, right? Because then it'll be easier to take the transverse view of the colon and and just come around once you're sort of -

No colostomy. No.

Thank you.

Okay, go ahead. So we have to get the colon here.

Yeah. I'm going to go higher.

Right there, yeah. Where you can sort of see the - yeah. Keep going there, yep.

Where's our opening again? It's right, uh... there. Right, it's right there. So you can get this stuff.

Get this little flap here.

Yeah, that's fine there. And then this thing you're going to have to get a couple times, it looks like.

Okay, this stuff here.

Okay. Go ahead. You can get that stuff, right?

Yep.

Duo's right there

Do that a couple times. Right there is where - right?

Yeah.

Okay.

Okay, let's see where we're at. Hold on. So this is still colon. Alright, that's good. So now, you can see it this way, you can get that. You can just get it, yeah.

Chop through that. And you wanna - go under there, yep, and then just get that stuff now. Get it. You want to do that a couple times. That's what - yes. Exactly. Look. It's a huge difference, isn't it?

And then I can come a little bit down. So now - that's omentum here, right? A little bit more?

This is still going to be - transverse still, yeah, so - this part - this is where it's…

Stuck.

It's all stuck, I think.

So let's see... maybe here, there, right?

If we can get through that, um - Okay, there you go.

Yeah, that's better.

So maybe we can starting see a - flexure, the apex, sort of. Close.

Okay. Oh, yeah.

So let's push that down. Yep.

Okay. And hold this up, still. Good.

Hold on.

Yeah, there.

Like that, okay. Go ahead.

And that extra lateral there.

No, I think the colon - yeah, get all that.

That little bit more there.

We did a lot of work underneath already, so it's going to be easy once we get past this - you know what I mean? It's like already gone there, almost. I think. Unless up here it’s more attached. I don't know, we'll see.

That's good.

Let me see here. Now if we take the colon this way, is this all - I think it might be all done.

It's coming.

There we go. There it is, see the edge right there? Let's see.

It's getting...

...up underneath there?

It's there… It's right here.

Yep. Good. And then follow that.

Yeah, on the colon side. I'll get this superficial stuff here.

Maybe come on over here. Go ahead.

Get that [...] at the end here.

Okay, go ahead. Just get started. Get lower so you can…

Yeah, like right there? Oh, you mean get lower here, right? That makes more sense.

And once we get going there - okay, go. Now fly.

And look up a little bit - yep.

And that comes there. Yep.

This is holding us up here, right? This is it. Get that, right?

Look up a little bit. Look up just a little. Okay. Yep. Okay, you're done?

There's still something holding us, I think. Up top. That's it.

Yeah, let's see where we are in terms of - where we want to take the colon. And whether we want to do - kind of an open, or - we've got to sort of figure that out. Can you look down more?

Interesting that his sigmoid is stuck up here, when it was like - kind of read as normal.

Well, this is more normal attachments, I would say. This is pretty normal attachments, it's coming easily, you know, it's not -

It's not that sticking.

So, let's see here. Hold on, we want to -

Get back in the right line.

Look up closer. So is this mesentery, or is this - ? I think it's just attachments, right? Yep.

Mesentery should be below us.

So you can go there. And hold on.

CHAPTER 5

So, let's look here for a minute. Look down. Good, now we can look down at rectum. Like that. Okay, and then we're looking up. And we're going to follow it up, and we're going to say - you know - maybe we should do it right here.

Yeah.

And the question is, do we -

Bring that out, or - ?

I mean, we could come across this and take it all out. The question is, could we get a stapler all the way up? What do you think?

Yeah, we could.

Alright, let's do this - take the LigaSure and start making an opening here. Do we have the 15 mm trocar?

That's fine. Just keep going, that's fine. Just have to chop through some of those. Can you get in there?

Yeah. I'm making some progress.

Right under here, see this? Can you get under me, or no?

Yeah. One lip right there. There.

That's good.

Under there. Yep. Alright. You're probably up through, but you've got to get more of a window.

Yeah, that's not enough. Hold on. Right - there. That's fine. Get it. I mean - because you have to get that other stuff.

Yeah. Then the other side. I'm going to get underneath and try to hold. I can still get a little bit more.

You can get some more. We have to get it eventually, anyway, so it doesn't hurt to - Okay, let's see here. Grab it there, that's better. Okay. That's the way to do it. I should have done that before. By opening up the -

So now we're going to go across the - We can staple across that.

Yeah, that looks clear.

And then we'll just keep going.

So let's do a 15 through there. Through here. Just a little bigger. It stretches out a lot.

Looks good?

Yep. Looks good. And I'll kind of help you. If you just put it there, it'll go like this. So go - and - We've got to be all the way across, no?

Yep, I'm just going to try to see -

There must be a little -

Niblet of tissue, yep.

See, it should be in there.

So you think we're not in the -

I think you went too low, sort of.

Okay.

Careful. Yeah, just go ahead in. I think it's because it's angled. But it's fine, go ahead.

Close it?

Yep.

Yep. Okay. Alright, take it?

Yep.

That'll be beautiful.

Just a little bit of mesentery left. Bowel looks good there. I'm going to go up above the staples here.

That's fine, it's just on - because it's on the staples.

Yeah, let me try to go above. I might have to use scissors or something to cut that. Because it didn't cut before.

Just cut it, it's fine. Get the big clip right there. Do we have the wound protector?

Yeah, let's go from there.

Okay. Do it twice.

Yeah, it's thick again, right? Yeah, I thought so too.

Seems a little thicker. I think what we'll do - go ahead. I think what we should do is, um - we'll just enlarge the umbilical, I guess. Bring stuff out.

And then through a midline, kind of?

Yeah. And make the ileal - little pouch with - set it - you know, have the handle in. And then, presumably put it in, unless we can - I mean, if it's right there and we can see it. I don't think it will be.

Yeah. The small one there. Yeah, but don't open it yet. That's the one that we'll use.

Yeah, the other side. Can you get it?

Yeah. Clip it twice.

We don't have that much more to go.

No.

Should be close. Unless we're going in a different spot somehow.

Let me make sure. So - I don't think so. Let's see. It's got to connect, right?

I'm sure it does.

I think there it is. I think. Look at that. Okay. So that's that.

CHAPTER 6

Okay, go in there.

Here it is.

CHAPTER 7

There's mesentery. Well, let's take the Bovie and just take that off first. Okay, and then - take the - I would take the LigaSure.

So we have the 100 GIA.

Like that. First ring here, and then put it back in. Okay, can we have the ILA, please?

Go ahead. Yeah. If you can - and just hold on to this here. And - go ahead.

Oh - no, let it go.

So make an opening - right here. Yep.

We'll take the reload.

Here, I’ll just go like this. I’ll take the other one.

And I'll take the bowel and line me up, okay?

Okay.

Yep. Keep going. Okay. Push.

Let me see it. Let it go.

Okay, 2-0 prolene, double-armed. That's dirty.

CHAPTER 8

So, just around and around. We'll do a baseball stitch. SNaP, please.

Outside-in. Okay.

And we're going to want the 28, right?

Now don't get too much. This has to all - I mean, make sure it's full thickness.

Yeah, it is.

And we'll take the, um - Okay, we're going to take the 28 EEA. Okay, so hold on here. 28, please.

Tie that down.

And go around. You have to get it underneath that, yep. Go ahead.

CHAPTER 9

Make sure you go deep - yeah, that's fine, I guess. As long as you just get deep enough to - yeah.

Okay, tie that up.

Just don't move your retractor.

And let's get the scope. 90%.

CHAPTER 10

Okay, come up with the scope. Go ahead.

Go ahead. Let's see if I can - Can you push it in?

Yep.

I want to see - yeah. I just want to see that. Okay. It's going.

Okay, keep going. Yep. Oh, that's good. Okay. Hold on. Yep. Okay, hold on.

Okay, now I'm going to turn this way.

Turn, turn, turn.

We made some progress there. So can I see where the staple line is? Is it below me?

Okay, hold on a second. Yeah, that's pretty much - alright. Rotate it a little bit more if you can. I'm just trying to think of what's the best place to come out. You're right, uh -

Can you feel me at the end, still? Because I came back a little bit.

Alright, just come out here, and that way we'll be - hold on a second, where are you? Down. Yes! Now - come out this way, go. Go. It's fine.

I'm going to come a little bit more center. There. It's opening. So now it's all the way out.

CHAPTER 11

Now let's watch it.

Alright. You want to show me the other side?

Go ahead. As you get closer, I'm going to pull this stuff out, so - I mean, I'll try to -

So that - You want me to open it again?

No no, keep going. It's just going to be some fat, it's okay. It gets squeezed and -

And the other side.

Make sure you're in the green. Okay? And then do it.

Ready?

Go ahead.

Okay. 10, 9, 8, 7, 6, 5, 4, 3, 2, 1.

Now open it up. Undo it a little bit, right?

Yep. Alright, open.

And then -

Slowly inching my way back.

Alright, we're going to check it with the scope.

CHAPTER 12

Okay. Let me get some insufflation in there.

Alright, go in. I think air is coming through, though, and - I don't see any bubbling so far. Yeah, there's no bubbling.

There. There.

Okay. Oh, there it is. Okay. Okay, suction that out. Try to suction all that air out.

Yep. You ready for me to come back after - You're happy with that view?

Yep.

Okay.

And there's no air bubbles, so, it's, you know - it looks good and there's no leak.

CHAPTER 13

I'm just going to take a look at the donuts.

Okay.

Two good donuts, actually. Circumferentially, it looks good.

CHAPTER 14

This is the cecum.

It doesn't matter, yeah, just - I'm just going to see - in this area is where he had most of the - adenoma. Actually pretty significant colitis here.

Do you have a sponge? So this is actually the - the main lesion in the cecum that we were worried about, is right there.

That long kind of polyp?

No, no, this - right here, if you can - it's a patch of -

This is a - sessile polypoid lesion. It's pretty bad colitis, actually, in the right colon. And it should be much better distally. So - He was supposed to do a prep, but it was not a very good prep. But the colon looks much better there, in terms of the colitis, that's pretty - relatively normal.

CHAPTER 15

[no dialogue]

CHAPTER 16

The operation, I think, went pretty well. It was a little bit more challenging than usual because of his chronic colitis and the transverse colon in particular was thickened, made the bisection a little more of a challenge, and also we had to make our incision, which was the enlarged infraumbilical port site, a little bit larger than I normally would do, just to get enough exposure so that we could make sure to safely remove the bowel and also get the J-pouch in good position for the anastamosis.

But generally it went fine and the leak test was negative and the patient ended up healing up very nicely. Went home after a couple days from the hospital, and we do have his final pathology back, which did show multifocal dysplasia, but no high-grade dysplasia, no cancer, all the lymph nodes are negative, so I think he's in good shape going forward. Of course, he'll have to have regular monitoring and surveillance of his remaining rectum, which will probably mean annual flexible sigmoidoscopes with extensive biopsies, just to make sure that there's no evidence of dysplasia in that section. But again, given that he has never had inflammation in the rectum, I think his risks of having a problem with the rectum in the future, either with inflammation or malignancy, are extremely low, so hopefully he'll have a good result. And so far he's doing well in terms of his bowel function, eating normally and having just 3 to 4 bowel movements a day.

Certainly one of the main issues after this operation is bowel function, how frequent the bowel movements will be. Generally with an ileorectal anastomosis, most people will have approximately 3 to 5 bowel movements a day, some people only 2. It certainly depends on how much of the rectum, and in his case even maybe a little bit of sigmoid colon was remaining, so - so there's a good amount of absorptive function in the remaining rectum.

Again, I make a small ileal J-pouch. It's not clear how much that helps, if it all, in terms of reservoir, but my sense is, anecdotally, over the years, having done this many times, that patients seem to do better than a straight ileorectal anastomosis, so - a lot of these patients'll have just maybe 2 or 3 bowel movements a day. So it's pretty good functional result, and certainly, I think, significantly better than the alternative, which would be a more standard ileoanal J-pouch, which generally requires 2 operations rather than 1 if we can do a temporary diverting ileostomy, so that's an advantage here. And secondly, the bowel function is much better with the rectum remaining. This kind of patient should have a pretty much normal life in the sense of being able to eat normal diet and just have a little more frequent bowel movements than average.

So the medical treatment of inflammatory bowel disease has improved significantly in recent years, especially with the introduction of all the biologics. I think they've made a big difference for a lot of patients in terms of improving their quality of life and improving the status of their bowel inflammation. In this particular patient, the problem was not so much the inflammation, which was under good control, and his bowel function was fine. It was the dysplasia. We assume that the dysplasia and eventual development of cancer in some patients is directly related to the extent of inflammation, the chronicity and degree of inflammation over time leading to dysplastic changes and so forth. It's still to be determined whether better medical treatment of the inflammation will prevent the malignancy that happens in some patients. The hope would be that over time, these patients, if they're controlled better in terms of the colitis, maybe won't develop dysplasia and eventual cancer at as a high a rate as happens right now, but we don't know that. That's going to take probably decades to figure that out.

I guess the other thing is that luckily he was diagnosed early enough that it turns out he was able to have surgery before anything turned into actual cancer. Having been around for many years and seeing many patients with IBD, I've seen a fair number of patients with advanced cancer. They can be difficult to diagnose because there's sometimes infiltrating type of lesions in the bowel that are not so easy to see. And again, you have to really be sort of on your toes with these patients. And it's good that he was able to be diagnosed early enough that - no cancer actually occurred and hopefully will never happen in him.

So I think there's some interesting lessons from this patient. One thing is that his symptoms were pretty subtle. In fact, his bowel function was really close to normal, and yet, he did develop dysplasia, precancerous lesions, so it just shows how important it is that we do colonoscopy regularly, especially on patients with inflammatory bowel disease. Even if they're not particularly symptomatic, the screening for dysplasia is really important. And luckily he was diagnosed before anything turned into cancer, so that was a good thing.