Single incision ("scarless") laparoscopic total abdominal colectomy with end ileostomy for ulcerative colitis

Total abdominal colectomy with ileal pouch-anal anastomosis is the intervention of choice for patients with medically uncontrolled ulcerative colitis. A three-stage approach is preferred in particularly debilitated patients. In this setting, laparoscopic surgery has shown to be safe, offering several advantages over the open approach. Single incision laparoscopic surgery is a new minimally invasive approach which represents a true scarless procedure for the first step of the restorative proctocolectomy. In this article, we describe our technique in performing the single-incision total abdominal colectomy.

The single-access device is inserted through a circular incision made at the ileostomy site, which was marked preoperatively. The procedure is performed with conventional laparoscopic instruments through one 12-mm and three 5-mm trocars introduced in the single-access device gel platform. Good exposure of the operating field is obtained by changing the Trendelenburg position and the lateral tilting of the table. We start the operation by mobilizing the right colon, then proceeding clockwise to the rectosigmoid junction. The ileocolic pedicle is divided after the visualization of the right ureter and duodenum. The right colon is mobilized in the medial-to-lateral fashion. The hepatocolic ligament is taken down, and the transverse mesocolon and the greater omentum are divided to mobilize the transverse colon. Subsequently, the lateral attachments of descending colon are taken sharply, and the avascular line of Toldt is bluntly dissected. Under direct visualization of the left ureter, 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 divided with an endoscopic stapler. The specimen is exteriorized, and the terminal ileum is divided extracorporeally. Finally, the ileostomy is matured in the standard Brooke fashion.

Between May and November 2010, we performed ten single-incision total abdominal colectomies, all completed successfully without complications or need of conversion, with a mean operative time of 139±24 min and an estimated blood loss of 100±120 ml. The postoperative course was unremarkable in all cases, with prompt return of bowel activity and short postoperative stay. In our experience, single-incision total abdominal colectomy has shown to be a safe alternative to standard laparoscopy in selected patients and appears to be a promising technique with the potential to improve short-term outcomes.