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Ileostomy Reversal for a Two-Stage Laparoscopic Proctocolectomy with Ileoanal J-pouch for Ulcerative Colitis

Derek J. Erstad, MD; Richard Hodin, MD
Department of Surgery, Massachusetts General Hospital

Transcription

CHAPTER 1

So this is a 29-year-old female who had a long history of medically refractory ulcerative colitis. And about 3 months ago, we did a laparoscopic proctocolectomy with ileoanal J-pouch reconstruction, and now she's here for ileostomy reversal. Before the reversal, I always do a gastrografin enema, which is shown here. Here's the side view, lateral view I should say, and the J-pouch fills up nicely. There's no evidence of leak. The contrast goes all the way back to the ileostomy bag. So, no obstruction. So, we're now going to go ahead and do her ileostomy reversal.

CHAPTER 2

Okay, hold on. All right, stop. It's easier to stop and then… And can we have Adsons, please, and a Schnidt? So we're going to keep this towel for dirty stuff, I'm going to leave that here, just so we're... All right, and I have a dirty table I set up. Okay, but this is all going to be dirty right there. Okay. Okay. Can I get a step please? Schnidt, please? Yup, let's get any red spots. Careful that's the bowel right there. Oh - here, we'll just go here. Just to make sure, out there first and then… Now, this is - yep. Do you have a couple Allises please?

CHAPTER 3

When do you want me to start sort of working my way towards the edge of bowel? Yeah, you can start doing this right - you can sort of see. Do you have a DeBakey, Deb? Mm hmm. Going to be right there - yep. Why don't you take that? And then we'll go like that. Okay. Okay, so now, I would say let's see how - yeah, I just wanna get a sense of how freed up it is or not. So you can, if it's easy, that's fine. There's some space there, but that won't want to come around and start - you want to go that direction? Sure. Like… free it up there. Do you have a Rich, Deb? Mm hmm. So I can feel the edge of the bowels right there, so we're going to just be careful and get… Hold on. Yeah. There it is. So we're going to want two firings of the 100 GIA. Yeah. Let's just get this right there, you can see the line. Yeah. If you grab it - grab the fascia and just pull it away a little bit. Yeah, there you go, yeah. That's the last little bit, I think. And then we should be freed up. Okay, nice. So now we have two beautiful loops of bowel. Very easy.

CHAPTER 4

So what we're gonna do is just put one in each side. Why don't you open this up a little bit with a Bovie? Just because the stapler goes in easier. Sometimes it gets a little fibrotic here where the skin is. We're going to take this off anyway, so it doesn't really matter. So that's one limb. And then the other one is like that so just open that up a little. And then we'll take the GIA separately, one at a time. Yeah. So this way it just goes in easily. Okay, so let's see. Let's do - do you see the… Let's see here, yeah, that's fine, there we go. Like in there and just, that's that, and I'll hold it like that. And then the other one, just follow the curve. Mm hmm. Yeah, can we get a 3-0 silk pop-off? So, I would say just with your hands, forget the forceps and just with your hands, just push up so that we get a nice apposition. The mesentery is safely underneath, you want to just put your finger below, you can just confirm that, yup. It's good, yeah. And we'll go all the way - okay, yep. And then we'll take a 3-0 silk. We'll just put a stitch in the crotch. Mm hmm. Needle back. So I'm going to fire this. We're going to take another load of the GIA. This is dirty.

CHAPTER 5

So while we're waiting I'm just going to look inside. I don't see any bleeding. That looks good, and then we're going to offset these, right? So we don't have crossing staple lines. So we'll kind of go like that. Mm hmm. Okay, and then I always feel the lumen, which is nice down to… Do you want it together now? Mm hmm. That's fine, so you can feel it goes right down to there. So, that should be fine just like that. Even down a little bit more just - closer to me, yep. Because it's plenty big - yep. Okay, so this is going to be a specimen: ileostomy site. We'll take a scissors for the silk. And then, okay so now this is the specimen, and then all of this is going to be dirty.

CHAPTER 6

So we're going to - yeah, go around and around just to reinforce this staple line and - good. Should I run it? Yeah, run it - yeah, pull it through a little bit so I can - scissors, please. Oh go ahead, keep it pretty close together. And forceps to me, please. Can I get a sponge? Mm hmm. Do we have some other 3-0 silk pop-offs? Yeah. Yeah, we may just put a couple more in along the… So here just make sure you get into nice healthy bowel there, you see it? Yeah, I'm going to bring it up right here. Yeah, yep. Let me just see something if this dunks eas- if it dunks easily, we could do it this way, just to - yeah, I think it's better, go ahead. I'm going to just keep that down for a minute, just so that corner's not stick- oh - push it in. Oh, you should be closer to - well, okay. Go, go - put it down, go ahead and pull it. Do one more time? Yeah, just go to here. Mm hmm. Okay, you can do maybe a - Do you have a SNaP to do like an instrument tie here, this? And I'll take a wet sponge, please. Okay, so that looks good. So, once again we have a nice wide anastomosis there. You feel it, right? Yeah, that feels good. Yep, another 3-0 silk. We'll just put maybe a couple of Lemberts in here to… So - you can just go like that without grabbing the bowel, if you just… Mm hmm. Mm hmm. Okay, so that looks good - scissors please. And then, the other side you can't really get at. I'm not gonna start causing too much trauma, so let's see if we'll get it back in, try to do this without much trauma to the bowel. We have to push a little bit, but I'm careful about the anastomosis. This one goes in pretty easily, that's good. And - there's actually no adhesions at all around there because with the laparoscopy we did a Pfannenstiel, but there's nothing around there at all. That's great. Wet sponge, please.

CHAPTER 7

Mm hmm. We want to get down to the nice white fascia. So, 0 Vicryl on the fascia. We need two of them and then the 4-0 nylons - I'm sorry, 3-0 nylons for the skin. Yeah, okay. So you can start off closer just so it's - yeah. So you hold it like that. Okay, hold on. And then we can look and kind of get a sense of what direction we should close the fascia. So, if we look at it, let's see, that's fine. It kind of looks almost like diagonal that way is going to come together the best way, like this is an apex. Yeah, I agree. Right? You see what I'm saying? Okay, so let's do 0 Vicryl, actually if you hold like this, I'll do it from this end. And Bonneys, please.

Okay, you can just take that off, it's fine. Just put the retractor in just to expose it, yeah. Getting nice bites into that healthy fascia out there. I want to go - yeah. Do you have the other 0 Vicryl? Yes. Yeah, so that feels good. We'll go like that. Scissors, please. And a couple more of, you know, a couple extra, okay. So this elliptical incision, you know, gives you pretty good exposure. I mean that's the advantage, I think. As opposed to just staying right on the mucocutaneous junction with a small circular incision and closing it that way. Nice exposure and you get a nice closure of the skin, usually it heals up pretty well, the transverse scar. Pull them both up tighter, okay, scissors. Can I have some Betadine to pour in, please? Okay, that looks good. We're going to do a little bit of antisepsis that there's not great scientific proof, but I think it seems to work well. Can we have saline now, please? Suction. I want to get rid of all the… And we'll do the local anesthesia next, and then we'll close the skin. Sponge, please. So let's take the local anesthesia. I'll take the retractor and expose it for you.

We'll get sort of the fascia, all around, and then we'll also get the subcutaneous. So this is 0.5% Marcaine diluted so it's 0.25% total, which means you should be able to use 1 cc/kg Probably around 60 total would be the most. More superficial there. Do you have more local, please? I do. And then more irrigation. Irrigation, please. That's fine, and a dry lap, and then we'll take the 3-0 nylons.

Let's check for hemostasis. Nope, we're all done. The last thing we want is a wound hematoma in this field.

So, we'll do some… Nylon? We'll do some vertical mattress. We'll try to keep them as loose as possible. Because with the post-op swelling, it's almost always too tight. I usually leave these in a minimum of 2 weeks, even up to 3 weeks since there's some tension on the skin closure, you know, since we've done the elliptical sort of removed skin, there's going to be some tension, so I leave the stitches in a pretty long time. Can I get a clean sponge, please? So, what kind of diet do you want to give her? I think for her, let's just start her out with clears and see how she does. Yeah, that's fine. So remember, she's a J-pouch patient, no colon, the expectation is that she'll start moving her bowels within 24 hours. Mm hmm. Very rare to not be within 24 hours, that would be a sign of maybe a problem like obstruction or something. So - and I would say typically they stay in the hospital either 1 or 2 nights - depends how they're doing in terms of, you know, bowel movements and diet. I keep in touch with these patients pretty closely, especially over the course of the first month or two, in terms of their bowel function. With a J-pouch, there's sort of an adaptation phase I would say, the first 3 to 6 months for some patients, it can be difficult with frequent loose stools. Not everyone, but - so, and then usually by about 6 months, they're kind of reached kind of a steady... Do you want one more? One more and that will be good. And then I generally do an initial post-op pouchoscopy on these patients at - yeah, keep it loose now, go ahead - at 6 months or so, take a look on the inside, just make sure everything is healthy and normal. Then after that, it depends on their history. If they have a long history of ulcerative colitis, they, you know, there's still some risk of dysplasia, malignancy, although very very low risk. So, they get either annual or maybe every 2 year pouchoscopy exams with biopsies of the rectal cuff and the J-pouch.