Ravi N Ambani, MD, MBA, James McCormick, DO, Ari Reichstein, MD. Allegheny General Hospital
Introduction: In this video, we demonstrate the use of the existing ileostomy site to perform a robotic single incision (SILS) completion proctectomy with creation of an ileal pouch anal anastomosis (IPAA) and diverting loop ileostomy as a novel second stage of a three stage procedure for Ulcerative Colitis.
Methods and Operative Procedure: The patient is a 25 year-old female who initially presented with severe, medically refractory ulcerative colitis. She underwent a robotic total abdominal colectomy with end ileostomy four months prior. She now presents for completion proctectomy and ileal pouch anal anastomosis creation. Our procedure was initiated by performing a takedown of the prior ileostomy. After creation of a 15 cm ileal J pouch, it was then reintroduced into the abdomen and a SILS port was placed through the existing fascial defect. Dissection of the rectum was started posterior to the rectum within the mesorectum and extended into the avascular presacral space. Anterior dissection was then carried out until the rectovaginal septum was identified and developed. At this point the rectum remained only tethered by the lateral stalks bilaterally which were then taken with the vessel sealer. Once circumferential dissection was complete and the levator muscles were identified, the rectum was divided with a reticulating stapler. The staple line was oriented in an anterior to posterior direction. Digital rectal examination was performed prior to introducing the stapler through the anus and above the anal musculature. An EEA anastomosis was created between the anus and pouch. The small bowel proximal to the pouch and mesentery were then repositioned to ensure no twisting or kinking of the mesentery. Prior to firing of the stapler, a finger was placed into the vaginal vault and the stapler was wiggled to ensure the vagina was not incorporated into the staple line. Revaluation revealed no tension on the anastomosis or twisting of the mesentery after our anastomosis was made. The rectum was retrieved through the existing wound and a more proximal diverting loop ileostomy was created in standard loop-Brooke fashion.
Results: The patient was admitted to a regular nursing floor postoperatively and started on a clear liquid diet. She was discharged to home on postoperative day 2 with return of bowel function.
Conclusion: Robotic SILS completion proctectomy with IPAA through the prior ileostomy site is a safe and alternative technique in the surgical management of Ulcerative Colitis.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87032
Program Number: V054
Presentation Session: Colorectal Videos Session
Presentation Type: Video