Limited Incision Ileorectal Anastomosis and Cholecystectomy: A Case Report

 Introduction: The trend towards minimally invasive procedures has progressed rapidly over the past several decades. Novel techniques and new technologies are constantly being introduced to perform increasingly complex procedures through very limited incisions. Utilization of an ostomy site for laparoscopic colorectal surgery has been described. We performed a cholecystectomy and ileorectal anastamosis (IRA) through an end ileostomy site using a novel flexible laparoscopic platform.
Case: A 35 year old female who underwent a total abdominal colectomy with end ileostomy for postpartum fulminant C. diff colitis. Prior to planned ileostomy reversal, she was diagnosed with symptomatic cholelithiasis. She subsequently underwent reversal of ileostomy with cholestectomy through the ileostomy site. First, a purse-string closure of the end ileostomy was performed followed by dissection and placement of 25mm anvil within the ileum. The end ileum was reduced back into the abdomen and pneumoperitoneum was established after deploying the SPIDER surgical platform through the ostomy site. The rectum was subsequently dissected free including adhesiolysis in the pelvis. Exposure was maintained using the flexible instrument delivery tubes to elevate the adnexa bilaterally. An additional 5mm port was required in the right upper quadrant to facilitate additional enterolysis for tension free anastamosis. An IRA was completed by grasping the anvil with the flexible instrumentation and engaging the stapling system in the usual fashion. We then performed a negative pneumatic leak test. The SPIDER platform was then rotated 180 degrees towards the gallbladder and cholecystectomy was performed. This step included additional right upper quadrant adhesiolysis to achieve the critical view of safety using flexible instrumentation. The ostomy site was closed with a wick for drainage. The patient was discharged on the fifth postoperative day. She continues to do well with resolution of her postprandial pain and good bowel function.
Discussion: Limited incision laparoscopic techniques are gaining acceptance and technological advances continue to broaden the scope of minimally invasive surgery. Several case reports of cholecystectomy, gastric band placement, nephrectomy, and colon surgery have been reported using these techniques. We present the first ileostomy reversal with IRA and concurrent cholecystectomy via flexible laparoscopy.
Conclusion: Flexible laparoscopy offers improve ergonomics, triangulation, and a stable camera platform which facilitates multi-quadrant/multi-organ surgery.

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