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  • 1. Introduction
  • 2. Surgical Approach
  • 3. Access
  • 4. Mobilize Colon
  • 5. Divide Distal Sigmoid Colon
  • 6. Pull Colon Through Infraumbilical Port Site
  • 7. Divide at Ileum and Make J-Pouch
  • 8. Secure Ileal End of EEA Stapler
  • 9. Regain Laparoscopic Access
  • 10. Insert EEA Stapler
  • 11. Anastomosis
  • 12. Test Anastomosis
  • 13. Reposition Omentum
  • 14. Examine Resected Colon
  • 15. Closure
  • 16. Post-op Remarks
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Laparoscopic Total Abdominal Colectomy with Ileorectal Anastomosis for Crohn's Colitis and Multifocal Dysplasia

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Winta T. Mehtsun, MD, MPH; Richard Hodin, MD
Massachusetts General Hospital

Transcription

CHAPTER 1

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 to 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 will 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. Yup. Mm hmm. Got it? Okay. To you. Mm hmm. That looks good. So let's just - yeah, take a gaze around. Take a look? This colon is a little bit big but whatever. Mm hmm. Yep.

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. Okay. And I'll vent us every once in a while so we can have a nice... These are little bit extra attachments, I think. Yeah, exactly. Maybe because he's had a bunch of scopes and... They're not really quite - scopes and biopsies. Yeah, I don't know, you know, an attempted - I don't know. Or it's just a little bit of colitis stuff, but... Well, but I wonder if we should come up closer to the colon, actually, even though it's - that stuff is... Like here? Yeah, just go right there and - go ahead, get it. Yep. We'll make our way closer to the colon. If I go like this, you go opposite and kind of push down a little, just sort of see what happens, and... See that... This line? That's sort of like tending to push on - just push it away, yeah, just to kind of stay - make sure we're close, okay. That's appendix, there. Yep, yep. That's appendix there, right? So we want to... You can take some of that stuff now, you know, here. Uh huh. Yep. So then you can go kind of both directions up a little bit. Yep. And then the other - from the opening. Yep. Now go north, yep. Grab that stuff, yep. Yeah. Yes. See how we're getting a little closer to colon there? Yep. Go ahead there. Yeah, so that's too far away from the colon, so that's - but anyway, go up north. Get that - yep. And then kind of just - well... So can you grab the bowel? Sure. Try it, yep. Yep. See what happens if you lift it up and over. Yeah. You know what I mean, so it kind of lifts over like that. Yeah, lifting like that. See what I'm saying? Yeah, yeah. That's where we want to be. If I go like this, get this in here. That's the - see the plane there? Yeah, yeah - no, I know that 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. Yep. Yep, nice. See, 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? There? Yeah. Yeah. That's what I think. Yeah, right down there. Yeah, exactly. So let's - here, let's - so there's duodenum, for sure. Yep, that's duo there. Yep, yep. So now let's stay - just kind of get that plane a little. That plane, yeah. I can regrab to hold that up. So it's right there, and then - you see what I mean? And then... Yeah, there's duo. Yeah. Because then we want to be here. Put that in the center, if you can, yeah. I'm just getting these attachments, that way - the colon will come. We should be able to take this, though, right? Yep, I agree. This has got to be one of the... I think it's just a peritoneal attachment. Okay, so now - what's holding us up? So it's coming way off nicely. Yeah, over, yeah. Which is what we want. And I just want to make sure that this continues. There's some bands there, yeah. Okay, so now - let's say we take, now, omentum, and lift it up. Yep, exactly. Right? And let's just go and... Okay, where's my other... Okay, so now, lift it up this way, right? Okay. 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... Colon. Let me just see this thing here. Get some hemostasis on that. Okay. Yeah, now we should go back up there, yep. Let me just get this separated. Okay, so now - that's lesser sac, right? I'll hold it down so we can sort of see where it's going, you see what I'm saying? Yeah... And then I'm going to march along. All right, that all goes that way. Here, yep. Yep. Can you go in there with the scope a little bit more? Here. So that's appendix, right? Go ahead, grab that. Look down, there. So that's appendix. Here's colon. Can we get through? You think we're almost through there? Yeah. Is that - that is through right there. You're almost through. Yeah, that's through for sure. Yeah, you're there, now it's definitely better, yeah. You can see the back side of the colon. Yeah, 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. Yep. So we want to lift up - let's see, can you get your instrument in there? In my - yep, inside, yep. And I lift up like that, then this is - mesentery, right? Because then it'll be easier to take the transverse mesocolon and just come around, but once you're sort of... If it were free on this side, yeah. All right. Okay, go ahead. Right there, yeah, where you can sort of see it, yeah. Keep going there, yep. Where's our opening again? It's right, uh... there. There, yep. Right, it's right there. So you can get this stuff. Yeah, there, this stuff here. Off the - just make sure you're off the duodenum there. Okay, go ahead. You can get that stuff, right? Yep. Okay. Okay, let's see where we're at. Hold on. So this is still colon. All right, that's good. So now, you can see it this way, you can get that. Now we should be coming around here. Chop through that. Yep. Then you want to go under there, yep. All right, so this... And then just get that stuff now. And you want to do that a couple times. That's what - yes, exactly, look. Yeah, now I have a - difference, yeah. Makes a huge difference, doesn't it? And then I can come a little bit down. Yep. All right, this is - omentum. So now, that's all omentum here, right? We got to take that off. Take that off. See what happens to that, just - or you can go through it, that's fine. It's nothing - get it, grab it, grab it. I mean we have to get it off that - through - eventually off that whole thing, but... Okay, there you go. Yeah, that's better that. Maybe we can starting seeing the flexure of the apex sort of close. Almost. Okay, oh yeah. So let's push that down, yep, yep. Okay, and hold this up still. Mm hmm. Good. Hold on. And go like that, okay. Yeah, there. Go ahead. Yep. And that extra lateral there. Now I think the colon - yeah, get all that. Yeah, let's get that - that little bit more there. Yep, yep. Well yeah, 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 all... Yeah. Yeah, it's coming down now. Yep. It's like all ready gone there, almost. I think. I mean 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? Yeah. Yeah, nice. Yeah, I do. Let's see here. It's getting... Up underneath there? It looks like it's there. It's right here, yep. Yep, yep. Good. And then follow that. Yeah, on the colon side. I'll get this superficial stuff here. Mm hmm. Yep. Maybe come on over here. Yeah, yeah. Yeah, go ahead, take that.. Get that band here. And then... Okay, go ahead, just get started, grab... Get into that. Get lower so that you can, I mean if you can... Yeah, like right there? Oh, you mean get lower here, right? Well, yeah. That makes more sense. I mean, yeah. And look up a little bit - yep. Yep - sorry. Okay, go ahead. That's a little close. It's all right. Okay, so... So we're almost... Hold on, where are we going to go? See where we want to be, right there. Right there. Get in there, yep, go. That's where you want to be. Take it off the... Flexure? Yeah, and off the kidney. That's colon. Hang on a second, hold on. Look up, please. Can we have more shift to the patient's right? What's holding us is down there. Yep, I'll get it in a second here. Go get through that stuff up, right there, yep. Now, yeah, that's the - yep, yep. Hold on a second, I just want to make sure Okay, go ahead, that's - I guess you can get that. Let's see. This is holding us up here, right? This is - this is it. Look up just a little bit, look up, okay. Yep. Okay, you're done? There's still something holding us, I think, up top. Let's see here. Yep, that's it. Yeah, let's see where we are in terms of - where we want to take the colon. Yep. 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? That's 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. You know? Okay, okay. This is pretty normal attachments, it's coming easily, you know, it's not like that stuck. Yeah. It's not that thickened... Look up closer. All right, it's going there. So is this mesentery, or is this...? That looks like attachments, right? I think it's just attachments, right? Yep, yep. And the mesentery should be below us, so... So you can go there, yep.

CHAPTER 5

So, let's look here for a minute. Look down. See, now we can look down at rectum. Like that. Okay? And then we're looking up. Yeah, that's better. Okay. Yep. We're going to follow it up, and we're going to say - you know - maybe we should do it right here. Right there, yeah. And the question is, do we - do this... Bring that out, or...? I mean, we could come across this and take it all out. Yep. Yeah, the question is, could we get a stapler all the way up? Stapler that far up? What do you think? Yeah, we could. Alright, let's do this - take the LigaSure and start making an opening here. Yep. Yeah, go ahead. Do we have the 15-mm trocar? It's in the room. Mm hmm. That's fine. Just keep going, that's fine. Just have to chop through some of this. Yep. Mm hmm. Can you get in there? Yeah, I'm like making some progress. Mm hmm, right under here, see this? Yeah. One lip right there. Yeah, okay, that's good. There. Yep, just keep chopping away there, yep. Do that a couple times, please, yep. All right, probably I'm through, but you 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 that's... Yeah, on the other side. Come back for a second, I'm... So... I'm going to get underneath and try to hold. I can still get a little bit more. Yeah. You can get some more - we have to get it eventually anyway, so it doesn't hurt to... Okay, let's see here. Yeah, grab it there, that's better. Like that? Open it, that's the way to do it. I should have done that before. By opening up the - thing, it opens. All right, so now we're... So now we're going to go across the - We can staple across that. Yeah, yeah, yeah, yeah. That looks clear. And then we'll just keep going. So let's do a 15 through there - through here. Okay. Yeah, just a little bit bigger. It stretches out a lot. Okay. Looks good? It's the same. Yep, looks good. Okay. A little bit more. Okay. Okay. Right there, okay. All right. Yeah, I'll kind of help you, why don't you - if you just put it there, yeah, I'll go like this. So go, and go - so - we've got to be all the way across, no? Yep, I'm just going to try to see... There must be a little... Something. Hold on, hold on. Niblet of tissue, yep. But see, it should be in there. So you think we're not in the... Kind of - I think you went too low, sort of. Okay. Careful. Hold on. Yeah, just go ahead and... I think it's because it's angled. But it's fine, go ahead. Close it? Okay. Yep. Yep. Okay, take it? Yep. Yep. It's going to be beautiful. It's going slow. Okay. Okay. Yep. Yep. Just a little bit of mesentery left. Bowel looks good there. I'm going to go up above the staples here. Yeah, 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. All right, just cut it, that's fine, yeah. Get the big clip right there. Do we have the wound protector? What size? The really small one, or...? The really small one was really small last time. Probably the medium then. Yeah. Yeah, let's go for there. Yep, mm hmm. Okay. Do it twice because it's kind of thick. Yeah. Yeah, it's thick again, right? Yeah, I thought so too. Seems a little thicker. I think what we should do is we'll just enlarge the umbilical, I guess. Yeah, and then do a midline, kind of? Bring stuff out. Yeah, and make the ileal - little pouch with, and set it - you know, have the handle in. And then, presumably put it in, unless we can - I mean, if it's like right there and we can see it. Yeah. 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. We got to make sure - we got to get that. Yeah... Yeah. Can you get it? Yep. Clip it twice. Yep. 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? Eventually, it's got to be. I'm sure it does. Here to there, yeah. Yeah. I think there it is, I think. Yeah. Look at that, okay. So that's that.

CHAPTER 6

Because... Okay, go in there. There it is. Here it is, all right.

CHAPTER 7

This is mesentery. So let's take the Bovie and just take that off first. Yeah, Bovie. Okay, and then - take the - I would take the LigaSure. Mm hmm. Get this again. So we have the 100 GIA. Yep. And we're going to want the short ILA - the 52 I guess. Like that. Purse string here, and then put it back in. Okay. Okay, can we have the ILA, please? You can come across that I guess. Okay. All right. Okay. Go ahead. Yeah. If you can - and just hold on to this here. And - go ahead. Whoops - don't let it go. I'm not, I'm not. So make an opening - right here. Yep. Okay. We'll take the reload. Yep. Here, let me just go like this. Okay, I'll just go on that side. Mm hmm - take the other one. Okay, then the other side. Okay, so now take the bowel and line me up, okay? Okay. Okay? Yep, keep going. I just don't want to push tension on the bottom, yep. Okay, push. Let me see it. Let it go. Let go? Okay, 2-0 Prolene, double-armed. Mm hmm. That's dirty.

CHAPTER 8

So, just around and around. We'll do a baseball stitch. Snap, please. Outside-in. Okay? Yep. And we're going to want the 28, right? Now don't get too much. This has to all - I mean, you know, make sure it's full-thickness. Yeah, it is. Yeah, but I mean... Hi. Okay, how are you? Good. And we'll take the... Okay, we're going to take the 28 EEA. Okay. Okay, so hold on here. 28, please. Okay, tie that down. Mm hmm. Hold on. Mm hmm. Go ahead. And go around. I just want to... Get a lip. You have to get it underneath that, yep. Go ahead. All right, we're going to want scissors and then a little bit of saline.

CHAPTER 9

Mm hmm. Make sure you go deep - yeah, I mean, that's fine I guess, as long as you just get deep enough to - yeah. Okay, tie that up. Yep. Yep. Yep. And let's get the scope - 90%.

CHAPTER 10

Okay, come up with the scope. Go ahead. Okay. Go ahead. Let's see if I can... Can you push in? Yep. I want to see - yeah, I just want to see that... Can it go in? I know... Okay, it's going. Okay, keep going. Yep. Oh, that's good. Okay, hold on. Yep. Okay, hold on. What's that? Go ahead Okay, now I'm going to turn this way. Turn, turn, turn. Yep. We made some progress there. So can I see where the staple line is? Is it below me? Okay, hold on a second. Okay. Yeah, that's pretty much - all right. That's there, okay? 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 - Can you feel me at the end, still? Because I came back a little bit. All right, just come out here, and that way we'll be - hold on a second, where are you? Down. Yes! Now - come out with the spike, go. Okay. Go. It's fine. Want me to come a little bit more center? Well it's... There. It's opening. So now it's all the way out. Okay.

CHAPTER 11

Now let's watch it. All right. 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... Okay. So that... You want me to open it again? No no, keep going, keep going. Okay. There's going to be some fat, it's okay. It gets squeezed and... And the other side. All right, so... Make sure you're in the green. Okay? And then do it. Okay. Ready? Okay. Go ahead. Okay. 10, 9, 8, 7, 6, 5, 4, 3, 2, 1. Okay, now open it up. Okay. I mean, and Undo it a little bit, right? Yep. All right, open. Okay. Yep. Okay. And then... Slowly inching my way back. All right, we're going to check it with the scope. Yeah.

CHAPTER 12

Okay, let me get some insufflation in there. Okay, there we go. All right, go in. I think air is coming through though, and I don't see any bubbling so far. Yeah, there's no bubbling. Okay. There. There. Okay - oh, there it is, okay. Okay. Okay, suction that out. That's it. Okay. 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. Do you need like a - is there anything on there you can use Winta? Yeah, there is. Yeah, I'm good. Oh, okay, good. Two good donuts, actually. Circumferentially, it looks good.

CHAPTER 14

This is the cecum. 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

You know, 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 dissection 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, is 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. It's a 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. So - 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. 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 kind of 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. You know, 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.