JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 3, 1992 Mary Ann Liebert, Inc., Publishers
Brief Clinical
Report
Laparoscopic Total Proctocolectomy with Creation of Ileostomy for Ulcerative Colitis: Report of Two Cases WALTER R.
PETERS, M.D., F.A.C.S.
ABSTRACT
Laparoscopic techniques have recently been extended to the performance of segmental colon resections. We report two cases in which laparoscopic techniques were used to perform total proctocolectomy with ileostomy for patients with severe ulcerative colitis. Our experience encourages us that laparoscopic surgery will also prove to be of benefit for this subset of patients.
INTRODUCTION
Thelaparoscopy
cholecystectomy has led to a rapid expansion of the role of in the treatment of intra-abdominal surgical disease. Recent reports have described laparoscopic colon resection.12 These reports have described segmental colon resections such as right colectomy, sigmoid colectomy, and abdominoperineal resection. Reported herein are two cases of ulcerative colitis for which laparoscopic total proctocolectomy with creation of a Brooke ileostomy was performed. rapid acceptance of laparoscopic
Case 1 A 68-year-old white male with a 4 year history of ulcerative colitis was admitted to the hospital due to recent exacerbation of symptoms unresponsive to increasing doses of oral steroids. At the time of admission an acute left femoral venous thrombosis was also found. Bowel rest and high-dose intravenous steroids were instituted for the ulcerative colitis. Bleeding due to the ulcerative colitis precluded systemic anti-coagulation. Therefore, an intracaval filter was inserted. Aggressive medical treatment of the ulcerative colitis was continued for 10 days without significant improvement in symptoms. Despite the use of total parenteral nutrition, the patient's albumin was significantly decreased at 2.4 gm/dl and he remained anemic. Surgical consultation was obtained and total proctocolectomy with severe
Department of Surgery, Boone Hospital Center, Columbia, MO. 175
PETERS
ileostomy was recommended. It was felt that the patient's age was a relative contraindication to an ileoanal pull through procedure and the patient was not interested in a multiple stage procedure. In an effort to minimize his postoperative discomfort, as well as minimize postoperative wound healing problems, laparoscopic proctocolectomy was offered to the patient and was eagerly accepted. Case 2
67-year-old white male with a history of ulcerative proctitis was seen in consultation due to progressive symptoms of ulcerative colitis which had developed over the preceding 6 months. The disease had progressed proximally and became more severe, despite increasing doses of steroid therapy; he had failed to benefit from either steroid containing enemas or sulfasalazine. The patient had also undergone implantation of radioactive seeds for carcinoma of the prostate 8 months previously. Because of progression of his symptoms despite maximal medical therapy, proctocolectomy with ileostomy was recommended. It was felt that the patient's age and history of prostatic irradiation were relative contraindications to an ileoanal pull through procedure. He was admitted to the hospital for an elective resection. A
MATERIALS AND METHODS The patient was given a general anesthetic and placed in low lithotomy stirrups. This not only allows access the anus for the perineal dissection but also allows one member of the surgical team to stand between the patient's legs. (Because this operation involves dissection on both sides of the abdomen as well as from the upper regions of the splenic flexure down to the pelvis, the positioning of instruments and surgical team members is dynamic; the patient must be frequently rolled from side to side and placed in both Trendelenburg and reversed Trendelenburg positions.) It is also believed that placement of the trocars needs to be somewhat individualized based on the patient's body shape and position of the colon. Although this is an extensive procedure, it can be adequately performed by a surgeon, one assistant/camera operator, and a surgical scrub to
technician. Four large trocars consisting of two 10 mm and two 12 mm trocars are used for the camera and operating instruments. By utilizing two 12 mm trocars, more flexibility is provided in the placement of an endo-GIA stapling device (US Surgical, Norwich, CT); in addition, placement of a 5 mm trocar in the right lower quadrant facilitates suction and irrigation within the pelvis (Figs. 1 and 2). A 45 degree camera is utilized to improve exposure of the peritoneal attachments of the colon. The mobilization of the colon can be initiated on either side. It is preferable to first mobilize the sigmoid colon by dividing the lateral peritoneal attachments and then free the mesorectum from the presacral fascia to mobilize the rectum. A proctoscope passed per anus and manipulated by an assistant can be used to facilitate exposure of the mesorectum. The surgeon continues to mobilize the colon by mobilizing the descending colon and splenic flexure. The transverse colon is then freed from the omentum and finally, the right colon is mobilized. After complete mobilization of the colon, the terminal ileum is suspended from the abdominal wall using Mersilene tape passed through the abdominal wall on a circlage needle. The ileocolic vessels are divided with the endo-GIA. The same instrument is then used to divide the terminal ileum near the ileocecal valve. The middle colic vessels are individually clipped and divided and the sigmoid vessels are again controlled with the endo-GIA. After completing the division of the colonie mesentery, attention is turned to the perineal dissection. An intersphincteric dissection is begun and the pelvis is entered posteriorly. The dissection is completed circumferentially, allowing the entire colonie specimen to be withdrawn through the perineal wound (Fig. 3). The levator ani muscles are reapproximated and the perineal wound completely closed. The abdomen is then re-insufflated and inspected for hemostasis and the pelvis is irrigated at this point. The trocar placed at the site selected for ileostomy is then removed and the skin incision enlarged. The fascia is split longitudinally and the end of the ileum is brought through the abdominal wall. The abdomen is then re-insufflated a final time to check for any accumulation of blood in the pelvis during the time that the pneumoperitoneum was relieved. 176
LAPAROSCOPIC PROCTOCOLECTOMY
12 mm Midline 12
mm
10
mm
Ileostomy Site
FIG. 1 & 2. These illustrations indicate the trocar positions utilized for the two resections. It is believed that optimal trocar positioning must be individualized depending on the mobility of the colon and the height of the splenic flexure.
FIG. 3. This photograph of the resected specimen from our second case demonstrates that although the specimen consists of the entire colon and rectum and adjacent mesentery, it can be withdrawn easily via the perineal wound.
177
PETERS is drained with a 15 French round Jackson-Pratt drain placed through the 5 mm trocar. A percutaneous suprapubic tube may be placed at this time if voiding difficulties are anticipated. All trocars are removed, the pneumoperitoneum is relieved, and the ileostomy is matured.
The
pelvis
RESULTS The estimated blood loss for both procedures was approximately 500 cc. Neither patient required transfusion. Both patients developed function of the ileostomy on the second postoperative day and began diets the second postoperative day. In the second patient, a suprapubic tube was placed in the bladder due to history of prostatic irradiation and concerns that he may have difficulty voiding postoperatively. The first patient was physically ready for discharge by the fifth postoperative day, however, he had a pre-existing deep venous thrombosis and it was decided to start him on chronic anti-coagulation with Coumadin. His hospital stay was thus prolonged until the ninth postoperative day while the Coumadin dose was adjusted. The second patient was discharged from the hospital on the third postoperative day. Both patients were voiding satisfactorily at the time of discharge and were tolerating regular diets. In addition, both patients were thought to have significantly less postoperative pain than is typical following proctocolectomy.
DISCUSSION Since
laparoscopic colectomy is still in its infancy, it is important that careful patient selection be used to identify those patients most likely to benefit from the new procedure. Ideally, the patients selected for laparoscopic colectomy should have no history of extensive prior abdominal surgery, should not be obese, and should not have acute peritonitis. In addition, until the surgeon is convinced that the mesentery can be excised to the same extent as can be done via laparotomy, resection of malignancies for potential cure should be avoided. These patients were believed to be ideal candidates for laparoscopic resection in that they had had no previous abdominal surgery, were thin, and had a benign disease that involved only the bowel mucosa (ulcerative colitis).
Although the experience is anecdotal, it is believed that these patients had much less pain than the usual postoperative pain, were able to tolerate a diet much earlier than the average total proctocolectomy patient, and were at much less risk for developing major wound problems, since the largest incision was 3 cm and located on the perineum. Our second patient demonstrates the potential for a markedly shortened postoperative hospitalization. Since laparoscopic colectomy will be associated with a learning curve, as with every other laparoscopic procedure, most surgeons will probably find that segmental resections such as right colectomy, sigmoid colectomy, or even abdominoperineal resection will be technically much simpler to perform. However, this experience seems to indicate that laparoscopic surgery may well be an appropriate treatment option for selected patients requiring total proctocolectomy with ileostomy. REFERENCES 1. Jacobs M, Berdeja JC, Goldstein HS: Endose 1991;1:144-150.
2. Fowler DL, White SA:
Minimally invasive colon resection (Laparoscopic Colectomy). Surg Laparosc
Laparoscopy-assisted sigmoid resection. Surg Laparosc Endose 1991;1:183-188. Address reprint requests to: Walter R. Peters, M.D., F.A.C.S. 3401 Berrywood, Suite 104 Columbia, MO 65201
178
Brief Clinical
Report
Laparoscopic Total Proctocolectomy with Creation of Ileostomy for Ulcerative Colitis: Report of Two Cases WALTER R.
PETERS, M.D., F.A.C.S.
ABSTRACT
Laparoscopic techniques have recently been extended to the performance of segmental colon resections. We report two cases in which laparoscopic techniques were used to perform total proctocolectomy with ileostomy for patients with severe ulcerative colitis. Our experience encourages us that laparoscopic surgery will also prove to be of benefit for this subset of patients.
INTRODUCTION
Thelaparoscopy
cholecystectomy has led to a rapid expansion of the role of in the treatment of intra-abdominal surgical disease. Recent reports have described laparoscopic colon resection.12 These reports have described segmental colon resections such as right colectomy, sigmoid colectomy, and abdominoperineal resection. Reported herein are two cases of ulcerative colitis for which laparoscopic total proctocolectomy with creation of a Brooke ileostomy was performed. rapid acceptance of laparoscopic
Case 1 A 68-year-old white male with a 4 year history of ulcerative colitis was admitted to the hospital due to recent exacerbation of symptoms unresponsive to increasing doses of oral steroids. At the time of admission an acute left femoral venous thrombosis was also found. Bowel rest and high-dose intravenous steroids were instituted for the ulcerative colitis. Bleeding due to the ulcerative colitis precluded systemic anti-coagulation. Therefore, an intracaval filter was inserted. Aggressive medical treatment of the ulcerative colitis was continued for 10 days without significant improvement in symptoms. Despite the use of total parenteral nutrition, the patient's albumin was significantly decreased at 2.4 gm/dl and he remained anemic. Surgical consultation was obtained and total proctocolectomy with severe
Department of Surgery, Boone Hospital Center, Columbia, MO. 175
PETERS
ileostomy was recommended. It was felt that the patient's age was a relative contraindication to an ileoanal pull through procedure and the patient was not interested in a multiple stage procedure. In an effort to minimize his postoperative discomfort, as well as minimize postoperative wound healing problems, laparoscopic proctocolectomy was offered to the patient and was eagerly accepted. Case 2
67-year-old white male with a history of ulcerative proctitis was seen in consultation due to progressive symptoms of ulcerative colitis which had developed over the preceding 6 months. The disease had progressed proximally and became more severe, despite increasing doses of steroid therapy; he had failed to benefit from either steroid containing enemas or sulfasalazine. The patient had also undergone implantation of radioactive seeds for carcinoma of the prostate 8 months previously. Because of progression of his symptoms despite maximal medical therapy, proctocolectomy with ileostomy was recommended. It was felt that the patient's age and history of prostatic irradiation were relative contraindications to an ileoanal pull through procedure. He was admitted to the hospital for an elective resection. A
MATERIALS AND METHODS The patient was given a general anesthetic and placed in low lithotomy stirrups. This not only allows access the anus for the perineal dissection but also allows one member of the surgical team to stand between the patient's legs. (Because this operation involves dissection on both sides of the abdomen as well as from the upper regions of the splenic flexure down to the pelvis, the positioning of instruments and surgical team members is dynamic; the patient must be frequently rolled from side to side and placed in both Trendelenburg and reversed Trendelenburg positions.) It is also believed that placement of the trocars needs to be somewhat individualized based on the patient's body shape and position of the colon. Although this is an extensive procedure, it can be adequately performed by a surgeon, one assistant/camera operator, and a surgical scrub to
technician. Four large trocars consisting of two 10 mm and two 12 mm trocars are used for the camera and operating instruments. By utilizing two 12 mm trocars, more flexibility is provided in the placement of an endo-GIA stapling device (US Surgical, Norwich, CT); in addition, placement of a 5 mm trocar in the right lower quadrant facilitates suction and irrigation within the pelvis (Figs. 1 and 2). A 45 degree camera is utilized to improve exposure of the peritoneal attachments of the colon. The mobilization of the colon can be initiated on either side. It is preferable to first mobilize the sigmoid colon by dividing the lateral peritoneal attachments and then free the mesorectum from the presacral fascia to mobilize the rectum. A proctoscope passed per anus and manipulated by an assistant can be used to facilitate exposure of the mesorectum. The surgeon continues to mobilize the colon by mobilizing the descending colon and splenic flexure. The transverse colon is then freed from the omentum and finally, the right colon is mobilized. After complete mobilization of the colon, the terminal ileum is suspended from the abdominal wall using Mersilene tape passed through the abdominal wall on a circlage needle. The ileocolic vessels are divided with the endo-GIA. The same instrument is then used to divide the terminal ileum near the ileocecal valve. The middle colic vessels are individually clipped and divided and the sigmoid vessels are again controlled with the endo-GIA. After completing the division of the colonie mesentery, attention is turned to the perineal dissection. An intersphincteric dissection is begun and the pelvis is entered posteriorly. The dissection is completed circumferentially, allowing the entire colonie specimen to be withdrawn through the perineal wound (Fig. 3). The levator ani muscles are reapproximated and the perineal wound completely closed. The abdomen is then re-insufflated and inspected for hemostasis and the pelvis is irrigated at this point. The trocar placed at the site selected for ileostomy is then removed and the skin incision enlarged. The fascia is split longitudinally and the end of the ileum is brought through the abdominal wall. The abdomen is then re-insufflated a final time to check for any accumulation of blood in the pelvis during the time that the pneumoperitoneum was relieved. 176
LAPAROSCOPIC PROCTOCOLECTOMY
12 mm Midline 12
mm
10
mm
Ileostomy Site
FIG. 1 & 2. These illustrations indicate the trocar positions utilized for the two resections. It is believed that optimal trocar positioning must be individualized depending on the mobility of the colon and the height of the splenic flexure.
FIG. 3. This photograph of the resected specimen from our second case demonstrates that although the specimen consists of the entire colon and rectum and adjacent mesentery, it can be withdrawn easily via the perineal wound.
177
PETERS is drained with a 15 French round Jackson-Pratt drain placed through the 5 mm trocar. A percutaneous suprapubic tube may be placed at this time if voiding difficulties are anticipated. All trocars are removed, the pneumoperitoneum is relieved, and the ileostomy is matured.
The
pelvis
RESULTS The estimated blood loss for both procedures was approximately 500 cc. Neither patient required transfusion. Both patients developed function of the ileostomy on the second postoperative day and began diets the second postoperative day. In the second patient, a suprapubic tube was placed in the bladder due to history of prostatic irradiation and concerns that he may have difficulty voiding postoperatively. The first patient was physically ready for discharge by the fifth postoperative day, however, he had a pre-existing deep venous thrombosis and it was decided to start him on chronic anti-coagulation with Coumadin. His hospital stay was thus prolonged until the ninth postoperative day while the Coumadin dose was adjusted. The second patient was discharged from the hospital on the third postoperative day. Both patients were voiding satisfactorily at the time of discharge and were tolerating regular diets. In addition, both patients were thought to have significantly less postoperative pain than is typical following proctocolectomy.
DISCUSSION Since
laparoscopic colectomy is still in its infancy, it is important that careful patient selection be used to identify those patients most likely to benefit from the new procedure. Ideally, the patients selected for laparoscopic colectomy should have no history of extensive prior abdominal surgery, should not be obese, and should not have acute peritonitis. In addition, until the surgeon is convinced that the mesentery can be excised to the same extent as can be done via laparotomy, resection of malignancies for potential cure should be avoided. These patients were believed to be ideal candidates for laparoscopic resection in that they had had no previous abdominal surgery, were thin, and had a benign disease that involved only the bowel mucosa (ulcerative colitis).
Although the experience is anecdotal, it is believed that these patients had much less pain than the usual postoperative pain, were able to tolerate a diet much earlier than the average total proctocolectomy patient, and were at much less risk for developing major wound problems, since the largest incision was 3 cm and located on the perineum. Our second patient demonstrates the potential for a markedly shortened postoperative hospitalization. Since laparoscopic colectomy will be associated with a learning curve, as with every other laparoscopic procedure, most surgeons will probably find that segmental resections such as right colectomy, sigmoid colectomy, or even abdominoperineal resection will be technically much simpler to perform. However, this experience seems to indicate that laparoscopic surgery may well be an appropriate treatment option for selected patients requiring total proctocolectomy with ileostomy. REFERENCES 1. Jacobs M, Berdeja JC, Goldstein HS: Endose 1991;1:144-150.
2. Fowler DL, White SA:
Minimally invasive colon resection (Laparoscopic Colectomy). Surg Laparosc
Laparoscopy-assisted sigmoid resection. Surg Laparosc Endose 1991;1:183-188. Address reprint requests to: Walter R. Peters, M.D., F.A.C.S. 3401 Berrywood, Suite 104 Columbia, MO 65201
178
