We present a case of intramesorectal laparoscopic completion proctectomy and ileal pouch-anal anastomosis in a 34 y/o female who had undergone previous subtotal colectomy, Brooke ileostomy and preservation of rectosigmoid stump for severe ulcerative colitis. She had completed her family and was not concerned about fertility.
Intramesorectal dissection has been proposed in open surgery as a way to minimize pelvic nerve injury related to rectal mobilization. We wanted to assess the feasibility of laparoscopic intramesorectal dissection and ileal pouch-anal anastomosis as demonstrated in this video. The rectosigmoid stump is mobilized from the subcutaneous tissue where it had been previously placed at the lower midline extraction site and pushed into the abdomen. We then establish pneumoperitoneum using a small wound protector, a 12 mm port, a Penrose drain and towel clips on the skin to seal this area. We use a supraumbilical 12 mm port, 2 five mm ports on the right and left side along the transverse umbilical line and an additional 12 port in the right lower quadrant. We reutilize previous port sites as possible. We take down the residual sigmoidal vessels and the superior rectal vessels using an electrothermal vessel sealing device. Our intramesorectal dissection begins posteriorly and on each side of the rectum before approaching the anterior aspect. A Hegar dilator may be placed into the vagina to ensure its exact location and facilitate dissection at this level. The rectal dissection is completed circumferentially down to the level of the pelvic floor. We then transect the rectum at the anorectal ring generally using two cartridges of roticulating 45 mm endostapler. The specimen is removed from the pelvis. The Brooke ileostomy is fully mobilized, passed through the existing stoma aperture and retrieved through the extraction site to create a 12 cm J-pouch with the circular stapler anvil inside. The completed J-pouch is then replaced inside the abdomen and pneumoperitoneum reestablished using the same sealing technique we illustrated.
The stapler’s spike is advanced through the posterior aspect of the anorectal stump to minimize the risk of pouch-vaginal fistula. The appropriately oriented ileal pouch is then joined to the anorectal stump under direct laparoscopic vision to fashion a stapled ileal pouch–anal anastomosis. We typically create a diverting loop ileostomy which is wrapped with seprafilm and passed through the original stoma aperture. A presacral drain is placed through the left sided port site. This patient was discharged 3 days after surgery and had an uneventful postoperative recovery.
Session: Podium Video Presentation
Program Number: V032