The patient is placed onto a second operating room table in the prone jackknife position (Fig. 12.7 ) over soft chest and hip rolls. Bony prominences are padded and the buttocks are taped apart using heavy cloth tape. Attention is focused on the colostomy, which should not have any direct pressure on it if positioned off the hip roll. The fi eld is prepped with Betadine. The anus has already been sewn closed. After con­fi rming the location of the coccyx posteriorly, the ischial tuberosities laterally, and the mid-perineum anteriorly, an elliptical incision is made circumferentially around the anus. The Lone Star Retractor ™ (CooperSurgical, Trumbull, CT) is secured. The extrasphincteric plane is entered and followed to the levators (Fig. 12.8 ). The coccyx is palpated, and the anococcygeal ligament is divided posteriorly to enter the pel­vis. The surgeon’s fi nger is placed in this space and hooked around the levator muscles. A cylindrical dissection is per­formed, taking a circumferential portion of levator muscle with the specimen to avoid narrowing it and creating a “waist” [ 19 , 20 ]. The specimen is exteriorized through the posterior space, and the more diffi cult anterior plane is better visualized and dissected. In men, the dissection proceeds just posterior to the prostate and urethra. In women, the plane is developed between rectum and vagina. The surgeon’s fi nger can be placed in the vagina to help feel and expose this plane. Tumor involvement of the prostate or vagina mandates en bloc resection. In the case of a bulky tumor that cannot be exteriorized (or a narrow pelvis), the specimen is circumfer­entially dissected, disconnected, and pulled out through the pelvis. The surgeon may choose to open and examine the specimen on the back table or, ideally, in coordination with the pathologist to more accurately determine margin status.

The tip of the Blake drain is positioned deep in the pelvis. The perineal wound is thoroughly irrigated and hemostasis is ensured. The peritoneum is not closed primarily, as this cre­ates a closed space in the pelvis, allowing for accumulation of blood and fl uid that is at risk for becoming infected and contributing to perineal wound complications and pelvic abscess [ 21 ]. The wound is closed in layers, fi rst using one to two layers of 0 Vicryl fi gure-of-eight interrupted sutures, and then one to two layers of 2–0 Vicryl fi gure-of-eight inter­rupted sutures, irrigating with saline between each layer. The skin is reapproximated with loosely spaced 2–0 Vicryl sim­ple interrupted sutures. Local anesthetic (0.25 % marcaine with epinephrine) may be infi ltrated. A dry sterile dressing is applied.

your assistant and proceeding similarly to the description above. The pelvis is entered circumferentially at the level of the levators, fi rst in the posterior plane. As described above, a portion of levator is taken to avoid coning in on the speci­men. Upon completion of the perineal portion, a lap pad is tucked into the wound, and it is covered with an occlusive dressing (Tegaderm, 3M, St. Paul, MN) to prevent insuffl a­tion gas from escaping during the abdominal portion of the

The patient is in lithotomy position. The anus is sewn closed as described previously. Dissection is initiated either in the intersphincteric (benign disease such as ulcerative colitis) or extrasphincteric plane (for malignancy) (Figs. 12.8 and 12.9 ).

Biologic mesh has been shown to be safe for use in contaminated fi elds [ 28 ]. A drawback remains the signifi - cant cost, with prices as high as $30/cm 2 (compared to $2/ cm 2 for polypropylene). Use of biologic mesh has largely supplanted synthetic mesh for pelvic reconstruction in the contaminated fi eld, given the increased risk of bowel obstruction, bowel erosion and fi stulization, and mesh infec­tion. Both nonabsorbable ( GORE- TEX) and absorbable (Vicryl) products have been used as well.

Most of the intraoperative and postoperative complica­tions for laparoscopic APR are the same as for the open

Given the cost and likelihood of complications, it needs to be remembered that proctocolectomy is not an entirely elec­tive procedure. For many patients, their quality of life with IBD has deteriorated to the point that proctocolectomy, with either end ileostomy or reconstruction with an ileoanal

pouch, may be the only way to restore a reasonable quality of life. Also, the expense of surgery may be cost benefi cial in the long term. In one study, the costs of care for patients after recovery from proctocolectomy were signifi cantly lower than the costs of care prior to the procedure [

In general, patients with ulcerative colitis undergo procto­colectomy when there is a failure of medical management to control their disease. This can manifest in a number of ways, including worsening symptoms of abdominal discomfort, diarrhea, and neoplastic changes. The majority of these patients have been treated with an escalating regimen of medications, including powerful immunosuppressives. When a surgical approach is planned based on the results of a pathologic evaluation, it is critical that these results be reviewed by an experienced gastrointestinal pathologist (preferably two). Other indications include perforation and hemorrhage (which are relatively infrequent), side effects from medications, the wish to avoid medications in patients of childbearing age, and growth retardation in children and adolescents.

more complicated and more likely to engender short- and long-term complications. Therefore, a proctocolectomy is inappropriate in a patient who is metabolically depleted and malnourished, acutely ill/toxic, or otherwise unfi t for sur­gery. Obesity may also render an attempt at proctocolec­tomy and J-pouch inadvisable until the patient has lost weight.

As laparoscopic proctocolectomy will result in a permanent ileostomy for a patient with Crohn’s, there are choices regarding how to manage the distal anal canal. The two main options are ultralow-stapled transection or inter­sphincteric proctectomy. A stapled transection is reasonable in the absence of perianal disease. This approach is the most technically expedient, but there is the risk of a staple line dehiscence and subsequent pelvic infection. Also, there is the possibility of perianal disease arising from residual anal mucosa. It does, however, preserve the sphincter, which some patients fi nd reassuring when making the diffi cult decision to proceed with an operation. The alternative, an intersphincteric proctectomy, requires additional operating time but provides a more secure closure of the pelvic fl oor. These two approaches are likely equivalent—however, in patients with signifi cant perianal disease, we recommend intersphincteric proctectomy with debridement of all active fi stulas.

The burden of polyps and the likelihood of progression to cancer in patients with true FAP is generally an indication for proctocolectomy. Diagnostic evaluation and operative plan­ning for these patients should include a full colonoscopy, esophagogastroduodenoscopy (EGD), as well as computed tomography (CT) of the abdomen/pelvis. These evaluations are critical to planning appropriate treatment. Several issues regarding the patient’s status need to be determined prior to surgery.

Second, the extent of rectal polyposis needs to be closely evaluated. Patients with a minimal burden of polyp disease in the rectum may be candidates for total abdominal colectomy and ileorectal anastomosis. For highly selected patients, this option may provide better defecatory function and avoid the morbidity associated with proctectomy. The exact threshold, in terms of the burden of polyps, which mandates procto­colectomy (as opposed to ileorectal anastomosis) is hotly debated. No more than 10–20 polyps should be present, and if an ileorectal operation is planned, the rectum should be entirely cleared of polyps preoperatively. Even in patients with minimal polyp disease in the rectum, however, there will be a need for lifelong surveillance of the rectal remnant. The likelihood of a subsequent rectal cancer is still estimated at 5.5 % [ 9 ].

form of metastatic disease from undetected colon carcinoma or Gardner’s syndrome with intra-abdominal desmoid tumors. Finally, the purpose of an EGD is to examine for the presence of duodenal adenomas, which are a signifi cant source of morbidity for patients with FAP [ 10 ].

11 , 12 ]. It is important