Multimedia article. Laparoscopic restorative proctocolectomy for ulcerative colitis

With increasing experience, laparoscopic techniques have been applied even to extended colorectal operations as restorative proctocolectomy for ulcerative colitis and familial adenomatous polyposis.

A 36-year-old woman with a 7-year history of ulcerative colitis was transferred for elective surgery 6 weeks after an episode of toxic megacolon treated conservatively. The procedure was performed in modified lithotomy position using six trocars. After initial medial transection of the three main vascular pedicles of the ileocolic and middle colic vessels and the inferior mesenteric artery and vein, the colon was dissected free laterally, from the sigmoid orally toward the ileum. Special consideration was necessary for dissection of the omentum. The rectum was mobilized down to the pelvic floor in two steps, starting at the level of the promontory and the upper rectal stalks. It was transected at the level of the dentate line. Through a Pfannenstiel incision, the bowel was extracted. After transection of the ileum and removal of the specimen, a J-pouch was created. The anastomosis was completed laparoscopically using a double-stapling technique. Finally, a diverting loop ileostomy was created.

A total of 13 patients underwent surgery. The medium age of these patients was 25.5 years (range, 19-57 years). There was no conversion to an open procedure. The median length of hospital stay was 11.5 days (range, 7-107 days). Four patients experienced major complications, including one case each of pouch failure after arterial occlusion, pouch-vaginal fistula, infected hematoma, and intraabdominal abscess formation. There was no postoperative mortality.

For restorative proctocolectomy, laparoscopic techniques proved to be safe and feasible. With further experience, they may have the potential to become an appealing alternative to open surgery.