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20 Indications forBenign Disease oftheRectum
199
Ultimately, this resulted in lower leak rates and
thus improved clinical outcomes [6]. For this
reason, a modied two-stage or three-stage procedure is preferred for UC.Nowadays, the colectomy is often completed laparoscopically
with reduced postoperative complications,
reduced incidence of clinically signicant adhesions, and preserved fecundity [7]. Due to the
relative absence of adhesions with this approach,
the completion proctectomy can be done via the
Pfannenstiel incision or, alternatively, with a
combination of a single-port introduced via the
ileostomy site and a TAMIS platform, which
provides a minimally invasive option. There are
a number of reasons why the transanal approach
for completions proctectomy for UC might be
advised:
1. The Ta platform enables a tailored transection
of the distal rectum, thus assuring a precise
length of the rectal cuff and thus avoiding the
risk of a retained rectum.
2. Laparoscopic cross-stapling of the distal rectum has been shown difcult resulting in too
long cuffs and the necessity to use multiple
staple cartridges, thereby increasing the risk
for anastomotic leakage [8].
3. Using the TAMIS technique, the difculty of
the double stapling is obviated and is replaced
by a single-stapled (double purse-string) anastomosis [9].
4. The best plane of dissection is still being
debated. The TME plane is an avascular plane
and surgeons are used to do this for rectal cancer. In order to avoid nerve injuries, most IBD
surgeons would do a “bad” TME anteriorly
staying close to the rectum anteromedially. A
possible drawback of the techniques is the
relatively large pelvic cavity that remains,
which cannot be adequately lled with the
pouch, resulting (hypothetically) in a larger
presacral cavity. This may prevent a potential
anastomotic leak from sealing, and it could
create an opportunity for proximal small
bowel to become entrapped posterior to the
pouch. Alternatively, a close rectal dissection
can be applied, which hold the dissection
perimeter away from autonomic nerves, and,
keeping the surrounding “cushion of mesen-
tery” in situ, avoids a wide pelvic cavitation
and limits extra-pelvic space that can be problematic. Furthermore, it is suggested that by
preserving the mesorectum and its nerves, a
greater awareness of pouch lling is achieved
compared to removing the mesorectum, probably due to different proprioception provided
by proprioceptors that are intrinsic to the
mesorectum itself [10]. It should be noted that
top-down dissection close to the rectal muscle
tube and especially deep within the pelvis is
difcult because of lack of exposure due to the
mesorectal fat. In contrast, bottom-up dissection along the muscle tube of the rectum using
either the electric hook or vessel sealing
devices is relatively easy.
5. The Ta approach allows the pouch anastomosis to be completed with a single-stapled construction, and this obviates the need for a
double-stapled technique, which is associated
with problematic intersecting staple lines and
the “dog ears” on both sites of the circular
anastomosis [8, 9].
6. Combining the Ta bottom-up approach with
single-port top-down proctectomy via the
stoma site, abdominal access trauma is minimized, and the requirement for an incision for
the purpose of extraction or pouch creation is
avoided (Fig.20.1).
Technique
Preparation: Patients are managed perioperatively in an enhanced recovery program. Patients
are positioned in the Lloyd Davis position on a
short beanbag. The right arm is tucked and positioned alongside the body. The rectum is washed
out with an iodine solution. Prophylactic antibiotics are administered.
Procedure Described for a Single-Team
Procedure
Step I. The ileostomy is dissected and provision-
ally closed with a running suture to prevent
stool spillage. A single-port laparoscopic platform (GELPOINT Advanced Access Platform,
Applied Medical, Rancho Santa Margarita,
CA, USA) is placed in the stoma site. At the
200
Fig. 20.1 Transabdominal and transanal single-port platforms in place
W. A. Bemelman
then positioned. Using blunt retractors the
dentate line is exposed. The level of transection is marked +/–3cm proximal to the dentate line to guarantee a remaining rectal cuff of
+/–1cm after the double purse- string stapled
ileoanal anastomosis. The TAMIS platform
GelPOINT® Path Transanal Access Platform,
Applied Medical, Rancho Santa Margarita,
CA, USA, is inserted with two 10mm cannulas in the gel cap, as well as a valveless 8mm
trocar to allow for operation of the AirSeal®
Insufation System (ConMed, Inc., Utica,
NY, USA). Insufation pressures are set on
15mm Hg. In case of combined laparoscopy
and TAMIS, the pressure settings must be
increased to 20 mmHg because of the competitive abdominal pressure. Using the electrocautery hook, the bowel wall is
circumferentially transected, with care to
assure that the transection of the bowel wall is
full- thickness and circular (Fig.20.2).
Unlike the approach to taTME for cancer,
the rectal lumen is not closed, because in this
setting the rectum is blind-ending and because
it is thoroughly cleansed with iodine solution.
Next, dissection is carried out in close proximity to the rectum using electrocautery or ultrasonic dissection. Care should be taken to
maintain a plane near to the rectal muscular
tube and to avoid an outward extension of this
fascial level, releasing incisions are often
made to increase exposure to the abdominal
cavity. After establishing pneumoperitoneum,
adhesions and the length of the rectal stump is
assessed. The proctectomy is started bottomup, in order to prevent an early rendezvous
with the top-down dissection, because rendezvous between TAMIS and laparoscopy means
less exposure working via the TAMIS, bottom-up approach.
Step II. A perianal block is injected at 3 and 9
o’clock positions using 10 ml of an amide
local anesthetic (such as bupivacaine), with
5ml on either site to make the external sphincter muscle relax. The Lone Star Retractor
(Cooper Surgical, Inc., Trumbull, CT, USA) is
Fig. 20.2 Transection rectal wall full thickness
20 Indications forBenign Disease oftheRectum
Fig. 20.3 Close rectal dissection
plane, with entry into the mesorectal fat plane
(Fig. 20.3). The dissection next proceeds as
far as possible avoiding prematurely opening
the pouch of Douglas, because the moment
the connection is established with the abdominal cavity, the exposure of the bottom-up dissection diminishes. If connection is made, the
top-down dissection is started.
Step III. With the single-port platform inserted at
the stoma site, pneumoperitoneum and visualization of the abdominal cavity is established
laparoscopically. The procedure is simplied
when an additional 5mm trocar is inserted in
the left lower quadrant, which can be used at
the end of the operation to insert a pelvic
drain. The rectal stump is identied, and using
the ultrasonic vessel sealing device, the “topdown” close rectal proctectomy is initiated.
Often, the rendezvous can be made with the
bottom-up dissection quite rapidly (Fig.20.4).
The specimen can be extracted either transanally or via the stoma site.
Step IV. The mesentery of the small bowel is fully
mobilized over the pancreatic head and duodenum to obtain maximal length. Transverse
incisions are made over the anterior and posterior mesentery in order to increase pouch
reach. This can be done best with the electrocautery hook.
201
Fig. 20.4 Transabdominal view on the rendezvous with
the bottom-up dissection
Fig. 20.5 Exteriorized terminal ileum taking the connecting vessels to the inner arcade to increase length
Step V. Pouch creation. The terminal ileum is
exteriorized via the Alexis ring of the singleport platform. If there is still not enough reach,
the connecting vessels to the arcade of the terminal ileum can be ligated (Fig.20.5). Using
linear staplers a pouch of 10–15 cm can be
constructed. The redundant efferent loop is
removed with a linear stapler and oversewn
with a running suture to completely incorporate the blind loop into the pouch to avoid
future blind loop syndrome. An anvil is placed
in the base of the pouch and xed with a purse
string. The size of the circular stapler depends
on the diameter of the anus and the relative
length of the remaining rectal cuff. If the cuff
is relatively long, a larger diameter stapling
device can be chosen.
Step VI. Purse-string creation of the rectal cuff.
Using a monolament 0-Prolene or equiva-
202
lent, the purse string is made taking care to
create symmetric bites and to not have either
too much or too little bowel wall in the purse
string. The muscular layer must be
incorporated.
Step VII. Under laparoscopic control the pouch is
positioned in the pelvis without rotation and
without herniation of small bowel beneath the
mesentery. Transanally, a long clamp is
advanced to grab the tip of the anvil and pull
the tip of the anvil through the anal purse
string. With graspers the peritoneum and the
mesorectal fat is positioned alongside the
pouch to facilitate a smooth advancement of the
pouch in the pelvis. The anvil is mated to the
arm portion of the circular stapler. The stapler
is closed and red. Typically, the rectal donut is
quite thick as a result of the double purse-string
single-stapling technique. Having pneumoperitoneum the anastomosis is checked for leaks
(reverse air leak test). It might be useful to reinforce the anastomosis with interrupted or running suture. A pouch drain (Chap. 32) is
inserted in the pouch for decompression. In our
unit, it is a common practice not to defunction
the ileoanal anastomosis, accepting a leak rate
of ~10–15%.
Step VIII. Via the single-port access platform, a
pelvic drain is positioned after removal of the
additional 5 mm trocar. The position of the
mesentery and small bowel is checked. The
single-port platform is removed and the stoma
site is closed in layers. The skin is closed with
a monolament purse string (Fig.20.6).
The nasogastric tube is removed upon case
completion. The pelvic drain is removed after
48h. The suprapubic catheter is clamped in the
following days after surgery, and if there is no
retention after voiding, the catheter is removed.
Patients are allowed to have a liquid diet until the
pouch drain is removed at day 6. C-reactive protein is measured at day 4 and day 7. If there is any
indication of anastomotic leakage being clinical
symptoms or elevation of CRP at day 7, a CT
scan with oral and transanal contrast is performed. If a leak is identied radiographically,
the patient must be taken back to theater and an
W. A. Bemelman
Fig. 20.6 Final result of double single-port TAMIS proctectomy and pouch
ileostomy fashioned; an Endo-SPONGE is
inserted transanally via the anastomotic dehiscence in the septic cavity [11]. Typically, one or
two Endo-SPONGE exchanges are necessary to
have a clean cavity over a time period of a week
in order to resuture the anastomotic defect in the
following week. Using this protocol, we have
been able to close all ileoanal pouch leaks within
3weeks after diagnosis [12].
If the pouch has been defunctioned primarily
for any reason, one should monitor the plasma
CRPlevel, which can help elucidate a silent leak.
In addition, the anastomosis is routinely checked
endoscopically within 2–4weeks after surgery. If
there is a silent leak, Endo-SPONGE-assisted
early closure of the anastomosis is still feasible.
Preliminary Results
De Buck etal. [13] compared a cohort of nearly
100 Ta pouches to conventional laparoscopic
pouches in a three tertiary referral center study.
20 Indications forBenign Disease oftheRectum
203
It was demonstrated that the odds for postoperative complications were 0.52 times lower for the
Ta pouch patients compared to the patients who
had undergone a conventional laparoscopic
pouch. This nding was primarily attributed to
reduction in surgical site infections. Ta pouches
therefore seem to be a safe and promising alternative for conventional laparoscopic pouches, but
long- term data are still awaited with respect to
functional outcomes.
Ta Redo Surgery forPouch
Dysfunction
Pouch dysfunction is a serious long-term complication of this restorative procedure. Causes are
often multifactorial and can be medical or surgical in origin. Careful multidisciplinary assessment of the pouch is therefore mandatory to nd
the correct cause of the problem and decide on
the appropriate therapy. Cross-sectional imaging
and joint endoscopic assessment of the pouch are
essential in decision-making.
pouch advancement – that is, excising the
retained rectum and bringing down the pouch
to an appropriate cuff size (Fig.20.7).
(c) Redundant efferent loop of S-pouch.
S-pouches have an efferent loop (Fig.20.8).
This loop should not be longer than 2 cm,
because otherwise there is a risk of kinking
of the efferent loop causing evacuatory dysfunction. When the dysfunction from evacuation becomes chronic, the pouch enlarges
and decompensates, as it is unable to build
sufcient pressure to overcome the outlet
resistance. If the pouch is not too large, the
efferent loop can be shortened and a new
hand-sewn anastomosis made. In case the
pouch is already too large, probably the overall size of the pouch needs to be corrected as
well (Fig.20.9).
(d) Mega-pouch: Mega-pouches (Fig.20.9) can
develop as result of chronic outlet obstruction and particularly the larger reservoirs are
sensitive for this (e.g., S-pouches, W-pouches,
Surgical Causes of Pouch Dysfunction
(a) Dysfunction related to the rectal cuff length:
A rectal cuff that is of an improper length
may be resultant from the double-stapling
technique for performing the ileoanal anastomosis. The cuff should not be larger than 2
centimeters; otherwise this will result in a
retained rectum. It is believed that having
such a cuff has a role in the ne continence
discriminating passage of air versus uid.
The problem with having a long cuff (retained
rectum), however, is the occurrence of
cuftis in ulcerative colitis and recurrent polyps in familial polyposis. If these conditions
cannot be treated medically or by endoscopic
removal, respectively, the cuff requires surgical excision.
(b) Retained rectum: A retained rectum is
dened if the remaining rectum is >2 cm.
Proctitis of the retained rectum can cause
urge and increased bowel movements, thus
negatively impacting anorectal function. If
symptomatic, this should be corrected by
Fig. 20.7 Specimen of pouch on retained rectum
204
Fig. 20.8 Efferent loop
of S-pouch (arrow)
W. A. Bemelman
Fig. 20.9 Overdistended S-pouch before remodeling
and long J-pouches). If symptoms of problematic evacuation warrant a redo pouch, and
if the patients prefer not to have an ileostomy,
the pouch needs to be dissected and remodeled, or an altogether new pouch should be
fashioned (Fig.20.10).
(e) Chronic sinus: A chronic sinus is dened as
an anastomotic leak that persists for longer
Fig. 20.10 Remodeled pouch
20 Indications forBenign Disease oftheRectum
205
than 1year. These sinuses can be quite clinically evident and may be the reason that
prevents closure of a defunctioning ileostomy; or the sinus(es) can be clinically
silent causing pouch dysfunction often misdiagnosed as refractory pouchitis [14].
Cross-sectional imaging is therefore imperative in case of chronic pouch dysfunction
(Fig.20.11).
(f) The failed pouch. The top three causes for
pouch failure are Crohn’s disease
(Fig. 20.12), prior anastomotic leakage/
pelvic sepsis, and refractory pouchitis [15].
The chronic dysfunctioning pouch can be
diverted with an ileostomy. If symptoms
persist (e.g., severe perianal stula in
Crohn’s disease or uncontrollable anal discharge), it is best if the pouch is excised.
The remaining space within the pelvic cavity must be lled, and typically omentum or
small bowel mesentery is placed in the cavity in order to prevent abscess formation in
the pelvis.
The patient is placed in the Lloyd Davis
position. A perianal nerve block is done to
relax the external sphincter muscle. A Lone
Star Retractor is secured to expose the
anorectum.
Cuff/efferent loop excision Depending on the
level of the pouch-anal anastomosis, the rectal
mucosa is incised just below the ileoanal anastomosis using either retractors or the TAMIS
platform. If the ileoanal anastomosis was
already at the level of the dentate line (e.g., as
is the case for an S-pouch), care must be taken
not to damage the internal sphincter muscle.
Transection of the muscular layer should be
done at the level of the ileoanal anastomosis in
Surgical Approach
(a) Transanal excision of cuff, retained rectum
or efferent loop, and sleeve advancement of
the pouch with or without transabdominal
mobilization of the pouch
Fig. 20.11 Endoscopic image of sinus (left), MRI with sinus (arrow, right)
Fig. 20.12 Crohn’s disease in pouch
206
W. A. Bemelman
order to preserve the internal sphincter muscle. In case of cuftis, a mucosectomy can be
done to preserve the internal sphincter muscle.
Careful dissection of the distal pouch or the
efferent loop is performed. If mobilization of
the distal pouch and cuff or efferent loop proceeds successfully (Fig.20.13), the mobilized
portion can be exteriorized via the anus, the
cuff or efferent loop can be excised, and a
hand-sewn anastomosis can be constructed. If
bottom-up mobilization is insufcient, either
open or laparoscopic mobilization of the
proximal part of the pouch and its mesentery
must be performed. In the latter case, it is
advisable to defunction the hand-sewn anastomosis (Fig.20.14).
Retained rectum
The rectal wall is tran-
sected 2–3cm cranial from the dentate line.
Applying a close rectal dissection technique,
Fig. 20.13 Transanal view on TAMIS mobilized pouch
Fig. 20.14 Distal part of pouch can be exteriorized for
excision
the retained rectum is dissected until the ileorectal anastomosis is encountered. Thereafter,
the pouch is carefully mobilized in order to
preserve the pouch. Since the pouch must be
brought down over a considerable distance,
either laparoscopically or via an open (i.e.,
Pfannenstiel or low midline) incision, mobilization of the pouch and its mesentery is
necessary to gain the additional reach
required. After freeing the pouch, including
the pouch rectal anastomosis and the retained
rectum, the latter two are excised. Preferably
a single- stapled, double purse-string ileoanal
anastomosis is constructed, thereby creating
a union between the pouch and anus. This
removes another 1.5cm of rectal cuff. In the
end, a small rim of cuff 1–1.5cm is preserved
for better ne continence (Fig.20.15).
(b) Transanal and transabdominal mobilization
of the pouch with revision of the pouch or
new pouch in case of mega-pouch or chronic
pelvic sepsis.
Again, the patient is placed in the Lloyd
Davis position; a Lone Star Retractor is
placed transanally and a perianal nerve
block performed. The TAMIS platform is
also utilized for Ta surgery. Depending on
the type of prior ileoanal anastomosis,
hand-sewn after mucosectomy or double
stapled, the rectal cuff is transected just
below the anastomosis avoiding any damage to the internal sphincter muscle. A
mucosectomy and transection of the muscular wall at a higher level might be appropriate. The rst part of the bottom-up dissection
can be done using retractors or via the
TAMIS platform. The bottom-up TAMIS
dissection proceeds as far proximal as possible after which the rendezvous is made
with the top-down dissection of pouch and
its mesentery. The completely detached and
mobilized pouch can be remodeled. In case
of revisionary surgery for a mega-pouch,
the pouch must be reduced in size. Care
must be taken in case of reducing the pouch
in size longitudinally, so that the vascularization to the remaining pouch is not compromised (Figs.20.9 and 20.10).
Dorsal line
y
20 Indications forBenign Disease oftheRectum
Fig. 20.15 Schematic
excision of cuff
(Litzendorf etal.) [16]
207
Mucosal
proctectom
Dentate line
Dentate line
208
W. A. Bemelman
In case of pelvic sepsis, the pouch is often
reduced in size due to brosis, and the required
excision is of this brotic distal part of the
pouch. Quite often, a blind loop is present,
giving the opportunity to enlarge the pouch by
incorporating the blind loop into the lumen of
the pouch using linear staplers. Presacral
sinuses must be carefully debrided to prevent
recurrent abscesses. The ileoanal anastomosis
is made using a hand-sewn technique, with
interrupted 3-0 Vicryl sutures; defunctioning
is routinely performed. A pelvic drain is left in
place for 48 h and 5 days of antibiotics are
prescribed in the patients that were operated
on for an index diagnosis of pelvic sepsis.
(c) Transanal and transabdominal intersphincteric
excision of the pouch with omentoplasty in case
of pelvic sepsis or Crohn’s disease of the pouch.
Similar to previous approaches, the patient
is placed in the Lloyd Davis position; a Lone
Star Retractor placed transanally and a perianal nerve block performed. The TAMIS platform is also utilized for Ta surgery. The
incision is done at the level of the intersphincteric groove. The intersphincteric plane of dissection is followed up to the ileoanal
anastomosis. Next, the TAMIS port is inserted
and the bottom-up dissection is proceeded via
TAMIS.Either via low midline laparotomy or
laparoscopy when feasible, the top-down dissection is proceeded until the rendezvous is
made. The pouch is excised and an end-loop
ileostomy is made. If there is sufcient omentum, a pedicled omentoplasty is created after
careful debridement of any septic pockets in
the pelvis (Fig.20.16). If there is no omentum,
Fig. 20.16 Pediculized omentoplasty schematic (left) and in the intersphincteric wound (right)