What are the operative steps in a laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis?

Operative Steps in Laparoscopic Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis

Laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) should be performed in high-volume specialist centers by surgeons with expertise in this procedure to ensure optimal outcomes and lower complication rates. 1

Preoperative Considerations

• Patient selection: Primary indications include ulcerative colitis (refractory disease, intolerance to medical therapy, dysplasia/cancer) and familial adenomatous polyposis
• Preoperative imaging: CT measurement from terminal superior mesenteric artery to anus (>11 cm distance may predict difficulty in reaching the anus with the pouch) 2
• Port placement planning: Number and sites of ports should be determined based on patient anatomy

Surgical Approach and Setup

Initial Steps

1. Patient positioning: Lithotomy position with arms tucked
2. Port placement: Multiple ports (typically 4-5) strategically placed for optimal access
3. Pneumoperitoneum establishment
4. Initial exploration and assessment of anatomy

Colonic Mobilization and Vessel Ligation

1. Vascular Control:

   • Identify and ligate the ileocolic, right colic, middle colic, and left colic vessels
   • Document level and method of vessel ligation (tie, clips, staplers, energy devices) as this is relevant for subsequent imaging and potential revisional surgery 1
   • Consider preservation of the omentum to reduce risk of postoperative sepsis and bowel obstruction

2. Colonic Mobilization:

   • Begin with mobilization of right colon along white line of Toldt
   • Continue with transverse colon by dividing gastrocolic ligament
   • Mobilize splenic flexure and descending colon
   • Complete sigmoid and upper rectum mobilization

Rectal Dissection

1. Mesorectal Dissection:

   • Perform total mesorectal excision (TME) technique for optimal oncological outcome if dysplasia/cancer is present
   • Visualize and preserve autonomic nerves (periaortal, presacral) to prevent urinary and sexual dysfunction 1
   • Dissect to the level of pelvic floor

2. Rectal Transection:

   • Transect rectum at appropriate level (typically 1-2 cm above dentate line)
   • Ensure maximum length of anorectal mucosa between dentate line and anastomosis does not exceed 2 cm 1

Pouch Construction

1. Terminal Ileum Preparation:

   • Identify terminal ileum and create adequate length for pouch construction
   • If needed, perform mesentery lengthening techniques:
     • Mobilization and incision of small bowel mesentery
     • Division of ileocolic vessels if necessary
     • Consider vein graft to superior mesenteric artery in difficult cases 1

2. Pouch Configuration:

   • J-pouch is most commonly used due to simplicity, reliability, and limited use of ileum 1
   • Document length of pouch limbs (typically 15-20 cm total length)
   • Create pouch using linear staplers (document number of stapler cartridges used)
   • Ensure proper orientation of mesentery to prevent twisting 1

Anastomosis

1. Pouch-Anal Anastomosis:

   • Options include:
     • Double-stapled technique (more common, preserves transitional zone)
     • Hand-sewn technique after mucosectomy (may be technically more challenging in laparoscopic approach) 2
   • Document anastomosis height in relation to dentate line 1

2. Anastomosis Testing:

   • Perform air leak test to ensure integrity
   • Assess perfusion of the pouch and anastomosis
   • Document status of the anastomotic rings 1

Diversion and Closure

1. Covering Ileostomy:

   • A covering loop ileostomy is generally recommended to reduce the risk of anastomotic leak complications 1
   • In select cases with no technical difficulties during construction, this may be omitted

2. Drain Placement:

   • Consider placement of pelvic drain
   • Document drainage technique 1

3. Specimen Extraction and Closure:

   • Extract specimen through a small Pfannenstiel or periumbilical incision
   • Close port sites and extraction site

Relevant Anatomy

• Vascular Anatomy:

  • Superior mesenteric artery and its branches supply the ileum and right colon
  • Inferior mesenteric artery supplies left colon and rectum
  • Adequate length of mesentery is critical for tension-free anastomosis

• Pelvic Autonomic Nerves:

  • Hypogastric nerves (sympathetic)
  • Pelvic splanchnic nerves (parasympathetic)
  • Preservation is essential to maintain urinary and sexual function

• Anal Anatomy:

  • Dentate line marks the transition between columnar and squamous epithelium
  • Internal and external anal sphincters must be preserved for continence

Potential Complications and Considerations

• Risk of non-reaching pouch is higher in male patients and with laparoscopic approach 2
• Pouchitis occurs in 0-11% of FAP patients but 15-20% in ulcerative colitis patients 3
• Lifetime pouch failure rate is approximately 15% 1
• Patients require lifelong endoscopic monitoring for development of adenomas in the anal canal (10-31%) or ileal pouch (8-62%) 3

Technical Pearls

• Careful "close rectal wall" proctectomy technique helps avoid impairment of sexual function in males 3
• Laparoscopic approach results in less wound infections, fewer intra-abdominal abscesses, and shorter hospital stay compared to open surgery 1
• Robotic-assisted laparoscopic surgery may offer technical and visual advantages in the pelvis 4
• J-pouch configuration is preferred for its simplicity and reliability over other configurations (W, S, or H pouches) 1