Alessandro Fichera, MD, Marco Zoccali, MD, Roberto Gullo, MD. Departement of Surgery – University of Chicago Medical Center – Chicago, IL
Total abdominal colectomy (TAC) with ileal pouch-anal anastomosis (IPAA) is the intervention of choice for patients with medically uncontrolled ulcerative colitis (UC) and in debilitated patients it is our practice to offer a staged approach. In this setting, laparoscopic surgery has shown to be safe, offering several advantages over the open approach[1-3]. Single incision laparoscopic surgery (SILS) has been proposed as a new surgical strategy in the effort to further reduce the surgical trauma[4-7]. For the first step, the total abdominal colectomy (TAC), SILS offers a true scarless procedure, using the ileostomy site as the only access point.
In this video we present a SILS TAC in a 38 years-old man with UC admitted for an acute flare. Aggressive medical therapy with corticosteroids and immunosuppressors had failed. The operative time (‘‘skin to skin”) was 110 minutes. There were no intraoperative complications or need for conversion. The postoperative course was uneventful; ostomy output was noted on the first post-operative day. A low residue diet was tolerated on the third post-operative day. The patient was discharged the following day.
A GelPoint® Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA) was employed as sole access to the abdominal cavity. One 12-mm and three 5-mm trocars are introduced through the gel platform, allowing to perform the procedure with conventional laparoscopic instruments, including a 12-mm 30-degree laparoscope and a 5-mm vessel sealing device for tissue dissection and vascular resection.
The GelPoint® is inserted through a circular incision at the level of the ileostomy site, marked preoperatively. We start the dissection from the right colon, beginning with the most challenging portion (below the access site) and therefore at greater risk of conversion and then proceeding clockwise to the rectosigmoid junction. The Trendelenburg position and side-to-side tilting of the table are dynamically adjusted in order to obtain a good exposure of the working area as described in the video. After having visualized the right ureter and the duodenum, the ileocolic pedicle is identified, dissected and divided. The ascending colon is completely mobilized in a medial-to-lateral fashion. The hepatocolic ligament is then taken down and the transverse colon is mobilized by dividing the mesocolon and the greater omentum. Subsequently the left colon is freed sharply from the lateral attachments and bluntly along the avascular line of Toldt. The left ureter is exposed and the inferior mesenteric vein and the branches of the sigmoid arteries are identified, dissected and divided. After switching to a 5-mm laparoscope, the rectosigmoid junction is dissected off the mesentery and divided with an endoscopic stapler. The entire specimen is exteriorized through the incision and the terminal ileum is divided extracorporeally. Finally, the ileostomy is matured in the standard Brooke fashion.
Program Number: V030