A restorative proctocolectomy with ileal pouch anal anas­tomosis (IPAA) is currently considered the standard of care for the surgical treatment of UC patients with good anal sphincter function [ 3 ]. Yet, this operation is not without its own potential morbidity, with the most common postopera­tive complications including intestinal obstructions from adhesions, wound infection, and pouch leak [ 4 ]. To decrease the incidence of pouch-related complications, a staged surgi­cal approach has been proposed [ 5 ]. Patients undergoing sur- gery for refractory UC are at high risk of postoperative complications in part due to immunosuppressive medical therapy, malnutrition, and the nature of the disease. Attempts at reducing surgical trauma and improving both short-term and long-term outcomes in this frail patient population have been made over the last two decades. One of the primary operative methods to achieve this has been the application of a minimally invasive approach to colorectal surgery, fi rst reported in the early 1990s [ 6 ]. However, widespread adop- tion has been relatively slow, especially in ulcerative colitis patients. The long operative time related to the complexity of the surgical procedure and the intrinsic limitations of the total laparoscopic approach have recently promoted laparo­scopic hand-assisted surgery (HALS), shown to be faster than the conventional laparoscopic surgery, while still offering the benefi t of the minimally invasive approach [ 7 ]. More recently, though admittedly much more technically demanding, satis­factory short-term outcomes have been reported after single­incision laparoscopic surgery (SILS) [ 8 ].

In our practice, a laparoscopic-assisted resection is currently the preferred approach to UC patients, with HALS being offered occasionally to the obese patient population.

To minimize complications, we have utilized a three­stage approach in patients with poor general condition and/ or treated with aggressive medical therapy. This approach involves (1) total abdominal colectomy and end ileostomy, (2) restorative proctectomy with IPAA and diverting loop ileostomy, and (3) ileostomy takedown. Alternatively, a two­step approach that includes (1) restorative proctocolectomy with IPAA and diverting loop ileostomy and (2) ileostomy takedown is offered to healthier patients.

The following chapter describes the different surgical techniques and reviews the evidence coming from the litera­ture regarding the optimal surgical approach to UC patients.

After induction of general anesthesia and placement of all the monitoring devices, the patient is placed in the lithot­omy position and secured to the bed. Both arms are tucked at the patient’s side. A single dose of preoperative antibiotic and subcutaneous heparin are administered, as well as stress dose of corticosteroids, if needed. A urinary catheter is inserted and rectal irrigation with diluted iodine solution is completed. The patient is prepped and draped in standard fashion.

In case of a conventional laparoscopic procedure, after a brief exploration of the abdominal cavity, additional four 5-mm trocars are placed in each of the four abdominal quadrants (Fig. 31.1 ). A more thorough exploration of the abdominal cavity is then performed.

Several pouch designs have been described, but it is our practice to perform a J-pouch. Handsewn IPAA with a trans­anal mucosectomy starting at the dentate line is reserved in our practice in case dysplasia is demonstrated by endoscopic biopsy irrespective of location and severity [ 9 ], while stapled IPAA is performed for the majority of patients without dysplasia.

hand sewn IPAA, a completion mucosectomy is performed transanally. The submucosa of the residual distal rectum and anal transition zone is infi ltrated with epinephrine containing local anesthetic solution to facilitate hemostasis. The circum­ferential mucosectomy is facilitated by placing a Lone Star™ (Lone star Co, Stafford, TX) retractor (Fig. 31.15 ). The inter- nal sphincter is visualized and preserved circumferentially, and given the typically short remnant, there is no need for anal dilation or aggressive manipulation of the sphincter com­plex. The electrocautery is our preferred tool for a precise and hemostatic complete mucosectomy starting at the dentate line. The pouch is then carefully advanced to the pelvis (Fig. 31.16 ), and after adequate hemostasis, a two- layer inter- rupted pouch anal anastomosis is constructed (Fig.

The mobilization of the intra-abdominal colon follows the previously described steps of a total abdominal colectomy all the way to the pelvis.

The monitors that were placed at the head of the table are moved to the foot of the table. The surgeon is on the patient’s right side with the assistant on the opposite side retracting the rectum up and out of the pelvis. Typically a medial to lateral approach to the mobilization of the inferior mesenteric artery is undertaken. The peritoneum overlying the sacral promon­tory is incised on the patient’s right side, and the left ureter is clearly identifi ed and mobilized off the operating fi eld. The hypogastric plexus is also identifi ed and preserved. Only after these structures have been identifi ed, the inferior mesen­teric artery is divided and ligated with a vessel- sealing device. The level of transection of the inferior mesenteric artery and vein follows the oncologic principles in presence of colorec­tal cancer. The total mesorectal excision plane is then entered, and this step of the procedure follows that already described for a proctectomy.

The IPAA construction follows the previously described steps for a proctectomy.