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Superior
c
9 Laparoscopic Proctocolectomy withtheConstruction ofanIleal Pouch-Anal Anastomosis
145
between the ascending colon mesentery and the
retroperitoneum in the region of the right pelvic
inlet (Fig.9.2). The conuence of the mesentery
and the retroperitoneum are scored using the
Fig. 9.2 Right colon dissection: A lateral-to-medial dissection expedites the surgery. The cecum is elevated
medially and cephalad with a Babcock, and dissection
begins at the pelvic brim
bipolar device, elevating the ascending mesocolon away from the retroperitoneum. This places
the conuence on traction and often exposes both
the duodenum and right ureter. This dissection
continues laterally to the right lateral wall, medial
to the duodenum and pancreatic head, and cephalad to the transverse colon. The terminal ileum
is pulled medially allowing for transection of the
lateral pericolic attachments from the cecum to
the hepatic exure (Pitfall 9.1).
Pitfall 9.1
c
The interface between the right colon
mesentery and retroperitoneum is a faint
white line. This line should be preserved
with the retroperitoneum to prevent
violation of the right colon mesentery,
poor oncologic margins, and bleeding.
Retraction of the right colon laterally exposes
the ileocolic artery. Even in obese patients, there is
virtually always an avascular region of the mesentery on either side of the ileocolic artery (Tip 9.3).
The avascular planes are opened with an energy
device, parallel to the ileocolic artery (Fig.9.3).
Fig. 9.3 After the right
colon has been
mobilized laterally, the
ileocolic pedicle is
ligated just distal to the
bifurcation of the
superior mesenteric
artery. A high ligation
optimizes the reach of
the small bowel into the
pelvis
Inferior
colic artery
mesenteri
artery
146
Hepatic
Gallbladder
D. B. Stewart
Identication of the duodenum prior to transection
can assist in preventing iatrogenic duodenal injury.
The ileocolic artery is then ligated just distal to the
bifurcation from the superior mesenteric artery
using bipolar energy, clips, or stapler.
Tip 9.3 Mesenteric Windows
c
Windows through the mesentery
represent the peritoneum without
underlying adipose tissues or vessels.
These windows appear darker than
surrounding mesentery. In thin patients
they may also appear slightly shiny and
translucent.
The energy device is used to free the attachments of the terminal ileal mesentery all the way
to the duodenum, maximizing mobility of the terminal ileum for the ileal pouch (Tip 9.4).
Tip 9.4 Ileocolic Artery in Pouch
c
Patients
While some surgeons prefer to preserve
the ileocolic artery, considering that the
pouch apex will be approximately 16
cm from the end of the terminal ileum, a
balance between length/tension
involving the pouch and blood supply
to the pouch must be met.
An energy device is used to transect the terminal ileal mesentery perpendicular to the bowel
wall. A stapler is inserted through the 12-mm
port at the ileostomy site (Tip 9.5), and the terminal ileum is transected just proximal to the ileal
cecal valve. This allows the right colon to be
tucked over the liver, out of the way for the
remaining portions of the surgery.
Tip 9.5 Bring Tissue to Stapler
c
The endostapler is bulky, and the
surgeon should bring the tissue to the
stapler, as opposed to moving the
stapler in the surgical field.
Step 4: Hepatic Flexure
The hepatic exure and transverse colon are
mobilized to the midline, toward the middle colic
vessels. Position the patient in maximal reverse
Trendelenburg positioning, and retract the
proximal transverse colon caudally and toward
the anterior abdominal wall with the Babcock
(Fig.9.4). Separate the transverse colon from the
omentum superiorly, and resect any remaining
retroperitoneal attachments above Gerota’s fascia
and the duodenum.
Create avascular mesenteric windows on either
side of the right branch of the middle colic vessel to safely isolate the vessels prior to transec-
Fig. 9.4 Hepatic exure
mobilization is
expedited by moving the
colon anteriorly and
caudally, exposing the
liver and Gerota’s fascia
flexure
Liver
Omentum
c
Ileocolic artery
9 Laparoscopic Proctocolectomy withtheConstruction ofanIleal Pouch-Anal Anastomosis
Fig. 9.5 The transverse
colon is retracted
anteriorly to expose the
middle colic vessels
which are sequentially
transected
Duodenum
Transverse
colon
147
Left branch of
middle colic artery
Duodenum
Superior mesentri
artery
tion. The transverse colon is retracted anteriorly
to expose the vessels (Fig.9.5). With the energy
device adjacent and parallel to each branch of
the middle colic vessels, a window is opened and
each vessel transected after isolation (Pitfall 9.2).
This process brings the duodenum into view once
again, allowing for a medial-to- lateral transection
of the proximal transverse mesocolon which will
mobilize the hepatic exure.
Pitfall 9.2
c
The middle colic vessels are an
additional danger point. Proximal
ligation can leave a short stump from
the MCA that can retract behind the
pancreas. Ensure that you have room for
ligation and good hemostasis while
transecting the MCA.
Step 5: Left Colectomy
Attention is next turned to the left colon. The surgeon moves to the patient’s right using a Babcock
for retraction in the left hand and an energy device
for dissection and ligation of vessels in the right.
The assistant stands cephalad to the surgeon,
retracting the colon as needed (via which port).
The patient is placed in maximal Trendelenburg
and right lateral decubitus positioning for this
portion of the surgery.
The choice of approach laterally to medial
approach depends on the redundancy and natural
position of the sigmoid colon (Pitfall 9.3):
Pitfall 9.3
c
Whether a medial-to-lateral or lateralto-medial approach is taken, isolation
of the ureter away from the IMA is a
prerequisite to prevent inadvertent
injury to the ureter before the IMA is
safely ligated.
(a) For a lateral-to-medial approach: The sig-
moid colon is retracted medially with the left
hand. The energy device is used to elevate the
sigmoid colon from the retroperitoneum.
Incision of the white line of Toldt reveals a second, deeper “white line” representing the
coalescence of the mesentery and retroperitoneum. This white line is preserved and is the
correct, bloodless plane of dissection. The sigmoid mesocolon is freed laterally until it is
medialized in order to isolate the left ureter from
the inferior mesenteric artery (IMA) (Fig.9.6).
(b) For a medial-to-lateral approach: The sig-
moid mesocolon is retracted toward the anterior abdominal wall with the left hand.
Identication of the IMA at the pelvic brim is
benecial in developing the avascular windows on either side of the IMA, which can
then be scored with the cautery. The Babcock
148
Descending
White line
ic
mesenter
D. B. Stewart
is used to grasp the mesocolon and retract
medially lifting the colon mesentery away
from the retroperitoneum (Tip 9.6). The
energy device bluntly sweeps the retroperitoneal tissues and ureters away from the IMA
in a lateral and dorsal direction.
Skeletonize the IMA and retract the colon
toward the anterior abdominal wall in the midline position. The left ureter should be identied from this medial perspective prior to
transection (Fig. 9.7). Ligation of the IMA
colon
Fig. 9.6 A lateral-to-medial dissection of the sigmoid
colon allows for visualization of the left and preservation
of the ureter and left pelvic side wall
of Toldt
with an energy device can be performed either
proximal to the bifurcation of the left colic
artery for malignant disease or distal to the
bifurcation in the setting of benign disease.
The remaining sigmoid colon and the
descending colon are mobilized (Tip 9.7).
Tip 9.6 Countertension for Obese
c
Patients
Especially for patients with visceral
obesity, placing the retracting
instrument closer to the junction of the
mesocolon and retroperitoneum will
provide better countertraction for
identification of the IMA and for safe,
time-efficient dissection.
Tip 9.7 Retracting in Two Planes
c
Optimized retraction often requires
retracting in two different planes. For
example, lateral mobilization of the left
colon at the white line of Toldt requires
retracting the colon medially and
anteriorly to provide the best exposure.
Fig. 9.7 The inferior
mesenteric artery is
transected after the left
ureter is identied
Inferior
vein
Colon
Inferior
mesenter
artery
Nerve
ic
Ureter
gastroepiploic vessels
9 Laparoscopic Proctocolectomy withtheConstruction ofanIleal Pouch-Anal Anastomosis
149
The colon is retracted toward the midline
and the anterior abdominal wall, while the
energy device is again used to sweep the
retroperitoneal tissue laterally, away from
the left colon mesentery. This process is
continued to the level of the splenic exure. Any remaining lateral pericolic attachments are transected. Mesenteric resection
will include a ligation of the inferior mesenteric vein (IMV) (Pitfall 9.4).
Pitfall 9.4
c
The duodenojejunal junction is deep to
the transverse colon mesentery at the
splenic flexure. Once the avascular
window is developed, identifying this
segment of the intestine avoids
collateral thermal injuries, including
those caused by lateral spread from the
energy device.
Step 6: Transverse Colectomy/Splenic
Flexure Mobilization
This portion of the surgery represents the most
potentially dangerous aspect of a proctocolectomy. The splenic exure is the convergence of
the spleen, the stomach, the duodenojejunal
exure, the pancreas, and the transverse mesocolon presenting many organs at risk for injury
(Pitfall 9.5).
Pitfall 9.5
c
Be certain to reflect the stomach
cephalad, avoiding injury to the
posterior gastric wall and differentiating
the transverse mesocolon from epiploic
fat to avoid bleeding.
The patient is placed in maximal reverse
Trendelenburg positioning right side down. The
surgeon and the assistant move to the patient’s
right side, with the operating surgeon using a
Babcock for retraction and an energy device for
dissection and vessel ligation.
Transection of the gastrocolic ligament at
its midpoint provides access into the lesser sac.
Transection then proceeds toward the inferior
pole of the spleen (Fig.9.8). This provides full
exposure of the lesser sac with visualization
of the posterior gastric wall, the pancreas, the
spleen, and the transverse mesocolon.
Attention is now returned to the middle colic
vessels for ligation. Windows are developed
mechanically on either side of the remaining
Fig. 9.8 After entering
the lesser sac, dissection
proceeds toward the
inferior pole of the
spleen, with full
visualization of the
posterior gastric wall
Short gastric and
Stomach
150
D. B. Stewart
middle colic vessels. Each vessel is isolated and
then transected with an energy device. This
approach allows for the non-dominant hand to
retract the mesentery anteriorly, away from the
retroperitoneum, using the mesenteric windows
to isolate each major arterial vessel and using the
energy device to ligate these structures. This
vantage point allows for a circumferential viewing of each vessel to ensure safety during the
ligation process (Pitfall 9.6).
Pitfall 9.6
c
The posterior gastric wall can be injured
easily and will sometimes extend more
caudally than the anterior gastric wall
which is readily in view. Opening the
lesser sac completely helps to prevent
gastric injury.
The remaining transverse mesocolon is
freed from the retroperitoneum. Using the right
hand, the transverse colon is retracted toward
the right abdomen. Additional retroperitoneal
attachments are transected using the energy
device, freeing the splenic exure completely.
At this point the entire abdominal colon, from
the right colon to sigmoid, is freed from its
attachments.
Step 7: Externalize theColectomy
Specimen (Optional)
with commercial device or closed in order to
continue laparoscopically. The expense of an
additional stapler/resealing device should be
balanced against ease of dissection (Tip 9.8).
Tip 9.8 Reestablishing
c
Pneum operi toneum
In multiport surgery, a wound protector
with removable top, similar to a hand
port, can be used to reestablish
pneumoperitoneum after colon
extraction and continue with a
laparoscopic approach. If a removable
top is not available, a small glove can be
used to occlude the port.
Step 8: Proctectomy
The assistant moves to the patient’s left side. The
assistant retracts the rectosigmoid colon with forceps under the mesorectum and putting the mesorectum on stretch in, up, and out (Fig.9.9). The
left ureter is identied, and the energy device is
used to transect any remaining attachments of the
rectosigmoid mesentery on the left. Transection
of the superior rectal artery, after conrming
location of the ureter on the left, provides access
into the presacral space (Tip 9.9).
Dissection begins in the posterolateral plane, in
a “U” shape around the mesorectum. The assistant
retracts the rectum anteriorly and cephalad, providing tension and space for dissection in the posterior
Externalizing the colectomy specimen prior to
performing the proctectomy prevents a oppy
colon from obscuring visualization during pelvic dissection. This is particularly true with
large colon and small peritoneal cavities and
in cases of obese patients, where visualization
may be difcult. In a single-site approach, the
presence of a trocar with removable top facilitates this step by allowing for easy reestablishment of pneumoperitoneum. In a standard
laparoscopic approach, an extraction incision
is created for removal. This can either be sealed
Tip 9.9 Mesorectal Dissection for
c
Benign Disease
The mesorectum can be preserved in
benign disease to decrease the
likelihood of pelvic nerve injuries and to
provide a cushion of adipose tissue to
support the ileopouch. This technique
is nonanatomic, it is not a bloodless
plane, and it is more time- consuming.
Rectum
Ureter
Hypogastri
Sigmoid colon
Internal iliac
9 Laparoscopic Proctocolectomy withtheConstruction ofanIleal Pouch-Anal Anastomosis
Fig. 9.9 The
rectosigmoid is elevated
anteriorly to the
abdominal wall,
exposing the posterior
mesorectal plane down
into the pelvis
Ureter
c
nerves
151
Fig. 9.10 Dissection
continues until the
pelvic oor is reached.
Transection should be
just proximal to the top
of the levator muscles,
minimizing remnant
rectal tissue
Ureter
Sidewall
External
iliac
midline. A thin lmy plane is visualized. With the
left hand, the surgeon provides additional upward
traction on the mesorectum, while the right hand
uses the cautery on the scissors to dissect in the
mesorectal plane. The correct plane should leave a
lmy surface on the mesorectum anteriorly, while
preserving the hypogastric nerves and presacral
fascia laterally and deep to the dissection.
As the posterior plane loses tension, the assistant retracts the rectum anterolaterally, to the
right or to the left, allowing for lateral mesorectal
Rectum
mobilization. The surgeon’s left hand provides
more traction, freeing the right hand to dissect
in the lmy, avascular plane on either side of the
mesorectum. Posterior dissection continues until
tension is lost, and then dissection begins laterally on each side in sequence. As the lateral tissue
is freed, greater traction can be obtained posteriorly by replacing the assistant’s retractor distally.
This is continued in a posterior, lateral fashion
until the levator oor is reached (Fig.9.10).
152
D. B. Stewart
The most difcult plane of dissection is
anterior to the rectum (Tip 9.10). Once the
anterior peritoneal reection is incised, the
assistant uses a bowel grasper to push upward
on the vagina putting tension between the
vagina and rectum or bladder and rectum. The
surgeon retracts the rectum proximally out of
the pelvis with a slight posterior angle. The
dissection is performed with a cauterized scissors or hook, parallel to the rectum, being
mindful of the prostate, vagina, and urethra,
which lie anterior to the plane by only a few
millimeters.
Tip 9.10 Retraction of the Uterus
c
A bulky uterus can be secured with a silk
suture on a straight needle. A suture is
introduced through the suprapubic
anterior abdominal wall and is passed
through the uterine fundus and back
through the anterior abdominal wall. In
males, the anterior peritoneal reflection
can also be retracted in a similar fashion.
The rectal mobilization is continued circumferentially to the anorectal junction. The goal of
this portion of the surgery is to remove the entire
rectum. Leaving a cuff of rectum can lead to
poor functional outcomes in pouch patients with
ulcerative colitis and increased neoplastic risks in
patients with cancer or polyposis. A digital anorectal exam conrms the distal extent of dissection (Fig.9.11).
Step 9: Transection oftheRectum
Laparoscopic stapling at the anorectal junction
can be challenging secondary to limited room
and the lack of right angle staplers. There is no
one right way to approach this portion of the surgery. Keys to proper transection include:
Fig. 9.11 A rectal exam helps to conrm the distal extent
of dissection prior to transection of the rectum
• Appropriate stapler location with respect to
disease state (Tip 9.11).
• Straight staple line to prevent ischemia.
• Minimize multiple stapler loads.
Tip 9.11 Confirming Margins for
c
Rectal Cancers
For patients with rectal cancers, a rigid
proctoscopy after the application of the
endostapler but before stapling can
confirm adequate margins. The specimen
should be opened on a back table to
ensure that the cancer has been removed
with a proper gross distal margin.
The rectum is retracted proximally and pos-
teriorly to expose the distal rectum at the anal
ring. The mesorectum will generally taper off at
the anorectal ring, but any remaining adipose tissue near the anorectal junction is transected. This
minimizes the volume of tissue introduced into the
stapler and prevents bleeding from the staple line.
Although the stapler can be applied in a num-
ber of directions, applying the stapler in an anterior to posterior direction is helpful in a narrow
pelvis or obese patients. In a female or patient
9 Laparoscopic Proctocolectomy withtheConstruction ofanIleal Pouch-Anal Anastomosis
153
with a wider pelvis, the stapler can be placed
from the right lower quadrant port, horizontally
across the rectum from right to left. It is crucial
that the rectum be manipulated to provide a staple line that is perpendicular to the rectum (Tip
9.12). For this reason, the assistant is often pro-
vided the stapler, while the surgeon manipulates
the rectum in the stapler jaws.
Tip 9.12 Creating a Perpendicular
c
Stapler Line in the Pelvis
With the stapler in place, use the right
hand to push the rectum distal to the
stapler on the right side of the rectum.
Pull the stapler with the left hand
proximal to the stapler, in effect moving
the rectum within the stapler, rather
than moving the stapler around the
rectum.
The surgeon performs a close visual inspection of the stapler placement laparoscopically and
a digital anal examination to conrm that the stapler is applied in a distal perpendicular position
(Fig.9.12). Every effort is made to transect the
intestinal wall with a single stapler application.
Fig. 9.12 Ensuring that the stapler is applied perpendicularly to the rectum minimizes excess staple loads and may
reduce risk of staple line leaks
This single staple line decreases risk of ischemia,
leak, or abnormal conguration of the anastomosis. The number of stapler applications applied to
surrounding fatty tissue is less important.
Step 10: Externalize theSpecimen
The specimen is removed through the single-port
device during a single-site approach or through a
small extraction incision in the case of a standard
laparoscopic approach. It is important to balance
the concern of making too many additional surgical sites, with being strategic about sacricing trocar sites that will be needed later in the operation.
For thinner patients, expanding the site of a
12-mm suprapubic trocar to a Pfannenstiel incision
can allow for removal of the specimen, pouch construction, and construction of the pouch-anal anastomosis. Pouch construction may require a larger
incision given the distal location of the anastomosis.
Specimen extraction and pouch construction
can also be made through the future stoma site. The
fascia of the site can be partially closed after pouch
construction and then reopened at the conclusion
of the surgery to construct the diverting ileostomy.
Step 11: Construction ofthePouch
Initially after externalizing the specimen, the surgeon should verify that there is adequate length
for pouch creation. A good rule of thumb for adequate length is if the apex of the pouch reaches
to the pubis. Internally, laparoscopic instruments
can be used to determine the anticipated apex of
the pouch internally and reach it toward the anus
as a surrogate evaluation. If the ileum reaches to
the anus easily, there should be adequate length
for pouch creation (Fig.9.13).
If the length is inadequate, the surgeon can
perform additional maneuvers in order to achieve
adequate mesenteric length. First, check to ensure
that the mesentery of the small bowel has been
fully mobilized to the duodenum. This can provide several centimeters of additional pouch
reach. If reach is still inadequate, careful elective
ligation of mesenteric vessels may be performed.
154
D. B. Stewart
If the ileocolic artery is intact, branches of the
ileal arcade may be transected, providing additional reach to the apex of the pouch. Prior to
transection of any branches, the branch should be
occluded transiently, with observation, to ensure
that the future pouch does not become ischemic.
If further reach is needed, scoring the mesentery
in a stair stepping mechanism can provide additional reach (Fig.9.14 and Tip 9.13).
Fig. 9.13 Internally, the reach of the pouch can be conrmed by pulling the pouch deep into the pelvis to the rectal stump. The pouch should reach easily, without tension
The pouch is constructed using open surgical
staplers through the extraction incision (Tip 9.14).
The terminal ileum is externalized, and a sterile ruler is used to measure a 15-cm length for a
J-pouch. The choice of the extraction/pouch construction site on the abdominal wall is generally
Tip 9.13 Failure to Reach
c
If the pouch does not reach to the anus,
the pouch can be hitched to anterior
sacrum with an absorbable braided
suture under a moderate amount of
stretch. This allows the pouch to stretch
and can be attached during an interval
surgery.
Tip 9.14 Pouch Conformation
c
J pouches are most commonly created,
with a 15–18-cm pouch. Other
conformations such as “S” pouch” and
“W pouch” can be created, as each
provides a slightly varied apex, which
may make reach to the anus easier.
Fig. 9.14 Stair stepping
is performed, scoring the
peritoneum covering the
mesenteric vessels. This
is done sequentially to
increase reach. Care
must be taken to prevent
injury to the underlying
blood supply to the
pouch
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