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412 Atlas of Gastrointestinal Surgery: The Colon
2. Mucosectomy
To perform a rectal mucosectomy with a hand-sewn ileo–anal anastomosis, the patient
is placed in a steep lithotomy position. The perianal area is prepped with Betadine.
An anal block is administered to keep the sphincter muscles relaxed during the muco-
sectomy and anastomosis. The technique for the block is described in the chapter on
Patient Positioning. The anal canal is inspected with a lighted rectal retractor. The
mucosectomy begins posteriorly, at the dentate line. This allows subsequent entry into
the posterior pelvis. The mucosa is elevated with an injection
of lidocaine and 1% epinephrine (25).
Mic pad previously placed
posterior to rectum
Bladder
Rectum
25
Anus
Anal sphincter
Mucosa injected
at dentate line
Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 413
The electrocautery or a scalpel is used to
elevate the mucosa within the anal canal off
of the underlying anal sphincter muscle com-
plex (26). The dissection is carried proximally
until the free pelvic space is entered (27).
26
Free
pelvic
space
Rectum
27
Dentate line
414 Atlas of Gastrointestinal Surgery: The Colon
Mucosa
28
The mucosectomy is continued laterally and anterior-
ly. The anterior mucosal dissection is performed last.
This is accomplished by grasping the mobilized
mucosa and retracting it posteriorly. A small
retractor is placed anteriorly in the anal canal and
is advanced as the dissection proceeds (28).
Once the circumferential mobilization is complete,
the proctocolectomy specimen is removed through
the abdominal incision.
Four 3–0 interrupted absorbable sutures are
placed through the remaining anoderm at the den-
tate line in the four quadrants of the rectum,
from the outside in (29). Four additional
3–0 absorbable interrupted sutures are
placed in a similar fashion between the
first four sutures. These eight sutures are
secured loosely to the edges of the
drapes, with the needles left on.
Sutures
passed through
anoderm
29
Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 415
30
Ileal J-pouch
pulled through
anal canal
The previously constructed ileal J-pouch, with its mesen-
tery oriented posteriorly, is grasped with a Babcock
clamp passed through the anal canal up into the
pelvis. The J-pouch is drawn down into the per-
ineum (30). The open end of the pouch should
be visible at the anal verge. Each of the previous-
ly placed quadrant sutures in the anal mucosa is
passed through the wall of the ileal pouch and
tied (31). The four interspersed sutures are
passed through the ileal pouch and tied in the same
fashion. Additional 3–0 interrupted absorbable
sutures are placed in areas to close any gaps in
the anastomosis (32). The anastomosis is
31
inspected with the lighted rectal retractor.
Sutures passed
through anoderm
and ileal pouch
32
416 Atlas of Gastrointestinal Surgery: The Colon
Oversewn staple line in
posterior wall of J-pouch
33
A large-bore Malecot catheter is placed
across the anastomosis and secured with a
2–0 non-absorbable suture (33). This
drain, with a collection system secured to
the open end, is kept in place for 5 days
following surgery.
Whichever technique is used (stapled anastomo-
sis or mucosectomy) the abdomen is irrigated with an
antibiotic-containing solution. A temporary
diverting loop ileostomy is created in the right
lower quadrant (34) at the previously
Ileal pouch-anal anastomosis
Anal sphincter
marked site, as described in the Loop
Ileostomy section of the Small Bowel chap-
ter. A closed suction drain is placed in
the pelvis through the left lower quadrant
and secured with a 3–0 non-absorbable
suture. The midline abdominal wound is
closed in layers.
Temporary
loop ileostomy
J-pouch
34
Laparoscopic Total Proctocolectomy with
Ileal Pouch–Anal Anastomosis
Operative Indications
Removal of the entire colon and rectum (1)
may be performed via an open or a laparo-
scopic approach. This anal sphinc-
ter–preserving procedure is performed for
colonic polyposis or ulcerative colitis that
is either refractory to medical therapy or,
on biopsy, shows intestinal dysplasia.
Following resection of the colon and rec-
tum, an ileal J-pouch is created extracor-
poreally, and anastomosed to the anus. A
temporary diverting loop ileostomy is cre-
ated in the right lower quadrant. The
quality of life following an ileal
pouch–anal anastomosis is very manage-
able, with the patient having approxi-
mately 5–10 bowel movements a day.
Right
colon
R. colic a.
Ileocolic a.
Middle
colic a.
Transverse colon
SMA
IMV
IMA
Left
colon
L. colic a.
Sigmoidal
branches
When performing total proctocolectomy
for dysplasia or colonic polyps, the ileocolic,
the middle colic, and the inferior mesenteric arteries are
divided at their origin to allow an adequate lymphadenectomy should
cancer be discovered in the resected specimen. Relative contraindica-
tions for a laparoscopic approach to this procedure may include obe-
sity and prior abdominal surgery.
Sigmoid colon
Rectum
1
418 Atlas of Gastrointestinal Surgery: The Colon
Preoperative preparation of the patient includes a visit with the enterostomal therapist for stoma marking, an optional
mechanical bowel preparation, intravenous antibiotics, and prophylaxis for deep vein thrombosis.
Operative Technique
Patient secured to table
The patient is placed on the table in
2
the supine position. General endo-
tracheal anesthesia is induced and a
Foley catheter is placed. The patient
is then put in the modified lithotomy
position, supporting the lower
extremities with padded stirrups.
Modified lithotomy position
The patient’s sacrum should be at
the edge of the table and the thighs must be kept as flat as possible, to avoid elevated thighs interfering with manipula-
tion of the laparoscopic instruments during dissection. Both arms must be padded and tucked at the patient’s side (2). If
the patient is obese, arm extensions can be placed and left at the side with the arms tucked. The patient must be secured
to the table to avoid shifting while in a steep Trendelenburg position during the procedure. Extreme tilt to the left and
right is often required. This is necessary to allow gravity to act as a retractor, keeping the small intestine out of the oper-
ating field. Securing the patient may be accomplished by placing a beanbag underneath the patient’s torso prior to posi-
tioning; by taping the patient’s chest to the table with foam egg crates and silk tape; or by securing both the chest and
the head to the table with padding and tape. After correct positioning, a tilt test is performed to ensure the patient does
not shift when in extreme positions. The patient’s abdomen is then prepped and draped. The video monitors are posi-
tioned on the left and right side of the patient to begin the procedure. The right-side monitor tower generally contains the
insufflator and camera equipment and therefore does not get repositioned during the procedure.
One 5/12-mm Hasson trocar, three 5-mm trocars, and one 5/12-mm trocar are used. Either laparoscopic Babcock
or nontraumatic bowel graspers are used to retract the colon and manipulate the small bowel and omentum. Two graspers
and an endoshears are used to perform the dissection. Division of the mesentery is performed with a vessel-sealing device,
endovascular staplers, clips, or endoloops. Vessel-sealing devices such as the Harmonic scalpel, LigaSure, or Enseal can
facilitate dividing the omentum, the colohepatic ligament, or the mesentery and can shorten the duration of the case. When
performing resection for cancer, a wound protector must be used to extract the specimen. An endoscopic stapler is used
to divide the distal rectum and a stapled anastomosis may be performed using the surgeon’s preferred technique and instru-
mentation. Alternate techniques include placing a TA stapler through a small Pfannenstiel incision to divide the rectum
under direct vision, or performing a mucosectomy and hand-sewn anastomosis.
5/12 trocar site
used for ileostomy
Laparoscopic Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 419
To begin the procedure, a 1-cm supraumbilical incision is made and
dissection is carried down to the abdominal wall fascia. The fascia and
peritoneum are incised and 2–0 absorbable sutures are placed
through the fascia to act as stay sutures. A Hasson trocar is placed
in the supraumbilical position, pneumoperitoneum is
established, and the camera is inserted
through the trocar. Under direct vision,
three 5-mm trocars are placed: one in
the left lower quadrant, one in the
suprapubic position, and one in
the right upper quadrant. A
5/12 trocar is placed in the
right lower quadrant (3).
Care is taken to avoid injuring
the inferior epigastic vessels by
transilluminating the abdominal
wall and by visualizing each trocar
as it is placed. A general rule of
thumb for the lower quadrant port
placements is to position them four
finger-breadths superior and medial to
3
the anterior superior iliac spine. Once
the ports have been placed, the abdomen
is systematically explored.
If operating on a female with a uterus, the uterus needs to be retracted superiorly and secured to the anterior abdom-
inal wall. A 2–0 non-absorbable suture is passed through the abdominal wall midline between the pubis and the supra-
pubic port. The needle is passed through the body of the uterus, brought back out through the anterior abdominal wall
within 1 cm of where it entered, and the suture is tied to itself. A four-by-four pad, folded between the tightened suture
and the skin, can serve as a buttress.
Having a 5-mm camera available is beneficial if the patient has adhesions. This allows a camera to be placed through
any port, facilitating visualization around the adhesions and adhesiolysis. The surgeon stands on the patient’s left side, to
begin the procedure by mobilizing the right colon. Placing the patient in the Trendelenberg position and rotating the right
side up will improve exposure.
420 Atlas of Gastrointestinal Surgery: The Colon
4
Peritoneal
attachments
divided
Right colon mobilized
Cecum
A bowel grasper is
used to grasp the appendix
and gently retract it towards the
left upper quadrant, exposing the later-
al peritoneal attachments of the right colon.
These attachments are released with endos-
hears, working in a cephalad direction (4).
Electrocautery is rarely needed for division of the
lateral peritoneal attachments.
The hepatic flexure is mobilized by means of
the electrocautery. Once the right colon has
been released, the surgeon’s attention is
turned to ligation of the vascular pedicle. The
right mesocolon is lifted anteriorly with a
bowel grasper placed on the mesentery
directly above the origin of the ileocolic ves-
sels. The vessels are divided within the mesen-
tery using a vessel-sealing device. If the patient
has cancer or dysplasia, high ligation of the
ileocolic vessels is performed by creating
mesenteric defects and dividing the ileocolic
artery close to its origin, using a vascular linear
stapler, vessel sealing device, or endoclips
5
Ileocolic
vessels
divided
Right colon
Ileum
(5). Care must be taken when mobilizing the
right colon out of the retroperitoneum to avoid
injury to the duodenum or right ureter.
Cecum
Laparoscopic Total Proctocolectomy with Ileal Pouch—Anal Anastomosis 421
Ascending
colon
mesentery
Divided
ileocolic
vessels
6
The remaining ascending colon mesentery is divided with a vessel-sealing device (6). To
prevent difficulties in finding the proximal small bowel staple line after the specimen is removed,
the small bowel should remain attached to the colon until the specimen is removed.
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