10 yr experience of laparoscopic ileoanal pouch surgery
Laparoscopic restorative procto-colectomy: a 10-year experience of an
Goede, Angela Reeves* AR Dixon.
Colorectal Surgery and Stoma care* Frenchay Hospital, North Bristol NHS Trust, BS16 1LT
Mr Tony Dixon.
Ileal pouch-anal anastomosis,
Laparoscopic restorative procto-colectomy, SILS, Single port surgery
Introduction. Restorative procto-colectomy with ileoanal pouch
is accepted as the definitive procedure in ulcerative colitis. The
potential benefits afforded by a minimal invasive approach make it appropriate
to consider provided that there is no adverse affect on functionality.
Methods. Electronic data were prospectively collected from all patients who
underwent laparoscopic restorative procto-colectomy (LRPC) from October 1999 to
Results. 72 patients (40 male), median BMI 24 (19-48kg/m2)
underwent LRPC over 10yrs: three had cancer. 42 had undergone a previous
colectomy (laparoscopic in 38). 40 underwent W-pouch construction via a
Pfannenstiel incision whilst 32 were J-pouches constructed and returned via the
ileostomy site;7 were single port procedures. The median operation time was
210 mins (75-330). There were five conversions (7%), one of which resulted
in an immediate pouch failure. Median
time to full diet was 36hrs (4-168hrs) with a median hospital stay of
7 days (2-64). There were 7
readmissions (10%). Complications included:
immediate (3%), early (22%) and long-term
(11%). The incidence of failure
(excision or indefinite diversion) was 2.7%. 67 stomas have been closed. All patients have spontaneity of
defecation, with a median pouch frequency/24hrs of four, including once at
night. 90% are fully continent and
98% able to defer during the day. None admit to new onset impotency, or dyspareunia.
Conclusion. Laparoscopic restorative procto-colectomy is safe
with good functional outcomes when performed by an experienced laparoscopic
Large, long-term randomized controlled trials of
laparoscopic surgery for colorectal cancer (MRC CLASICC1, COST2 and
Barcelona3 trials) have all concluded that it is not only safe,
but it is associated with better short-term outcomes and without any compromise
to long-term cancer survival. NICE recommends4 that NHS trusts
give patients the option of laparoscopic resection as an alternative to open
surgery provided that appropriately trained surgeons perform it.
Restorative procto-colectomy can also be
performed laparoscopically and some would say that ulcerative colitis lends
itself to this particular approach (young patients, benign disease)5 -13. However, when carried out in this situation, laparoscopic surgery is
both technically challenging and time consuming; findings that will no doubt
add to the ongoing debate regarding precisely how and where pouch surgery
should be conducted. The aim of this study was to report our up-to-date
experience of laparoscopic assisted and “total” laparoscopic restorative procto-colectomy
(LRPC) and highlight the difficulties encountered And the functional results
that can be obtained.
Patients and methods
A prospectively collected, password protected electronic
database of all colorectal laparoscopic procedures performed between October
1999 and April 2010 has been used to identify surgical outcomes in 72
consecutive patients who have undergone laparoscopic restorative proctectomy –
ileal pouch anal anastomosis (LRPC).
This has been cross-referenced with the same units stoma nurses database,
which contains additional data on functionality.
Operative technique: Our initial 3-port technique utilizing rectal
mobilization within the TME plane, close division of the colonic mesentery with
omental preservation has already been described9. A 6cm Pfannenstiel
incision was utilized in the first 40 patients to allow closure of the gut-tube
1cm above the dentate line, transection and retrieval of the rectum followed by
construction of a 12cm W-pouch. The pouch-anal anastomosis was then constructed
under direct vision using a double staple technique. A suitable portion of
ileum was chosen for the diverting loop ileostomy and drawn through the
enlarged 12mm right iliac fossa (RIF) port-site.
The remaining 32 patients underwent total
laparoscopic mobilization with the specimen delivered (divided rectum end first)
through the suitably dilated 12mm port placed at the site of the chosen
ileostomy. The gut tube was again divided
at the level of the pelvic floor but this time using an ATG45 (Ethicon Endosurgery, Bracknell, UK) introduced
from the RIF using two anterior-posterior firings. The secret in
performing this division is in fully dissecting and defining the “gut tube” at
the pelvic floor. A 20cm J-pouch
was created and returned for the pouch anal anastomosis to be carried out under
direct laparoscopic vision taking great care to ensure no twisting of the mesentery. The last 5 cases were carried out using
a single port approach (SILS) positioned at the proposed ileostomy site14.
Operative technique following previous subtotal colectomy: Pneumoperitoneum was established using a Verres
needle inserted in the left upper quadrant. This was replaced with a 5mm
optical port and 5mm 300 laparoscope. The latter was used to survey
a site for potential further ports or in deciding to go for an immediate
mobilization of the ileostomy (12mm port placed within a purse string once the
stoma was mobilized with additional 12mm umbilical and 5mm inferior RIF ports
i.e., the same as had been used for the previous colectomy)15. Single
port (SILS) restorative proctectomy (Olympus
Tri port, Southend, UK) was used successfully in two cases via the RIF
after first mobilizing the end stoma.
Postoperative care: Analgesia was delivered via a PCA in 34 patients
with oral morphine, diclofenac and intravenous paracetamol in the remaining 38;
the latter was augmented by bilateral transversus abdominals plane (TAP) blocks16
in 23 cases. Patients were allowed fluids as tolerated, mobilized the following
morning and offered a light diet. Discharge was determined by the stoma nurse’s
assessment of competency at management of the new loop ileostomy. Catheters were removed after two days.
assessment: All patients were
asked about pouch function (stool frequency per 24hrs and at night, ability to
defer, faecal incontinence, antidiarrhoeal medication and protective pad use)
as well as problems with micturition and sexual function (potency, ejaculation,
dyspareunia, faecal leakage during intercourse) three months post ileostomy
closure and annually thereafter. Incontinence
was reported as never, occasional (< twice/week), and frequent or frank
faecal incontinence. Complications
were divided into early and long-term.
Pouchitis was defined by the presence of fever, abdominal colic, bloody
diarrhea and appropriate histology changes. Failure was defined as the need for pouch excision or for a
defunctioning ileostomy for more than a year with the pouch in situ.
Laparoscopic restorative proctectomy (LRPC) was
attempted in 72 patients (40 males) of whom 42 (58%) had undergone a previous
colectomy & ileostomy (laparoscopic in 38). The median age was 39 years (range 16-80) with a median BMI 24
(19-48kg/m2). Three had a synchronous cancer (Duke’s A, C
and C) with a median nodal yield of 30; all were Ro resections. One cancer had not been diagnosed pre-operatively.
40 underwent hand sewn W-pouch construction via Pfannenstiel incisions whilst
the most recent 32 patients had J-pouches constructed and returned via the
ileostomy site. Seven underwent a SILS procedure (included two procto-sigmoidectomies
and ileo-anal pouch).
There were five early conversions (7%) due to
widespread, four-quadrant adhesions; only one conversion followed an “open”
colectomy. The median operation time was 210 minutes (range 75-330 minutes). Post-operative analgesia was provided
by PCA in 34 patients for a median of 36hrs (range 24hrs - 7 days); 80% of PCAs
were discontinued by 48hrs. Median
time to full diet was 36hrs (4hrs-7days) with a median hospital stay of
7 days (2-64). The median stay for the “incision less” patients was 5
days, falling to 4 days for the SILS cases (3-7).
Immediate intra-operative complications: There were two intra-operative complications. A case of immediate pouch failure from acute
onset ischaemia following construction of the pouch-anal anastomosis and
followed an early conversion (previous open colectomy). The second mishap occurred in spouting
the wrong end of a loop ileostomy.
Early complications included: gastric ileus (9), high-output
ileostomy (2), chest infection (2), ileostomy bridge perforation/pressure
necrosis and resultant wound sepsis, PE, coagulopathy, anastomotic bleed &
leak. There were no complications
following the seven SILS
cases. Two patients required a
blood transfusion (coagulopathy and anastomotic bleed). The latter occurred on
the first post-operative evening; laparotomy and evacuation of a haematoma followed
four days later. The same patient then developed a below knee DVT.
The wrongly spouted ileostomy was closed after a
normal contrast study on day 9 (patient developed a pouch-anal leak 5 days
later and the pouch was re-defunctioned). The loop ileostomy perforation occurred
in a male with a BMI of 32 and followed an ileus/chest infection. The stoma was
reversed and the wound debrided only for the closure to then leak. There was an additional Pfannenstiel wound breakdown following
a superficial infection. There
were no deaths.
patients were readmitted (10%): high-output ileostomy (2), reactive depression,
anterior anastomotic leak (drained at EUA), bolus obstruction at the junction of
the abdominal wall and ileostomy (2), one of which developed an external iliac DVT
and finally a patient requiring reassurance/immediate discharge home.
Functional outcomes: 67 covering ileostomies were closed at between 1
and 6 months; all but two patients are fully continent at one year and 98%
are able to defer during the day. One
a 67 year old women (not sexually active) reports occasional minor daily soiling
and the need to wear a pad as well as occasional nocturnal incontinence (an
offer to defunction the pouch has been repeatedly declined). The median pouch
frequency at one year was four/24 hrs including once at night (range 2-8)
with 28 (41%) reporting using anti-diarrheal medication. There have been no cases of histological
proven pouchitis; one patient reported having received two courses of
metronidazole prescribed by her GP.
There were no cases of new onset impotence in the 40 male patients: a 22
year old had a dry ejaculate for 10 weeks. Two patients have had elective cesarean sections.
Long-term complications and pouch failure occurred in 8 patients (11%): incisional hernia following
ileostomy closure (3), anastomotic stricture requiring dilatation (3) and a small
bowel volvulus at 11 months around the pouch (no intra-abdominal adhesions)
which lead to mesenteric ischaemia and death. The second “pouch failure”
occurred in the patient with the perforated loop ileostomy; a second leak
occurred after bowel continuity was restored for a second time. There have been no re-admissions with
small bowel obstruction since ileostomy closure and no patient has developed a
Late onset ODS type symptoms were reported by
three patients (two female, one of whom had undergone an elective section seven
years earlier) at one and six and seven years. Both responded to a period of intense biofeedback therapy
following banding and excision of the prolapsed anterior wall of the pouch in
Continuous technological innovation and
experience encourages surgeons to attempt more complex laparoscopic colorectal
interventions. The objectives remain the same: reduced postoperative pain,
early mobilisation, reduced rates of wound sepsis, rapid return of
gastrointestinal function, early discharge from hospital and return to normal
life, avoidance of incisional hernias and long-term improvements in cosmesis.
Although laparoscopic intestinal surgery has been employed in a variety of
settings, many traditionalists have been and remain deeply skeptical about its
application to inflammatory bowel disease.
That said, several specialist centres have shown
the feasibility of carrying out laparoscopic restorative proctocolectomy5-13with immediate complication rates similar to those reported with open
surgery but with a shorter overall hospital stay. A meta-analysis17
of nine studies (329 patients) compared open and laparoscopic RPC; 168 (51.1%)
underwent laparoscopic resection. Operative time was significantly longer
(86mins) in the laparoscopic group (p<0.001) and throughout the subgroup
analysis, but this finding was associated with significant heterogeneity.
Operative blood loss was lower (84mls) in the laparoscopic group. There was no
significant difference in post-operative complications. Although they reported a
median length of stay approaching 13 days for LRPC, a statistically significant
reduction in length of hospital stay was observed for LRPC in high-quality
studies and those studies reporting on more than 30 patients by 1.1 days
(p=0.02 in both subgroups) and studies published in or since 2001 by 3.0 days
(p=0.004) but not overall. The authors concluded that any potential advantage
of a laparoscopic ileal pouch surgery remains to be established. Our length of stay data are considerably
lower, yet similar to those recently reported by the Leeds group13
whose median length of stay was 6 (3-26) days.
This series represents our total experience of
LRPC and describes our move from using a traditional11-13,,15,17
Pfannenstiel incision to remove the specimen, transect the gut tube and create
a hand sewn W-pouch followed by a postoperative PCA (median stay 7 days)9,
through to “incision less” total laparoscopic resection with removal of the
specimen through the chosen ileostomy site and construction of a J-pouch
(median stay 5 days)11 to our current position of offering
single-port LRPC (median stay 4 days)14. This move has coincided with our move to “accelerated
recovery” using TAP blocks to avoid the unwanted effects of parenteral opiates
that delay recovery and discharge16.
The choice of
incision to complete the dissection and to deliver the specimen remains a focus
of debate. In much of North
America, Australasia17 and Europe11 a small
peri-umbilical incision with direct extracorporeal ligation of the mesocolic
vessels is popular. It remains our choice for specimen delivery when performing
resectional cancer surgery, where it is our belief that in combination with TAP
blocks, pain control is improved and recovery faster16,19. The fulcrum effect of using a linear laparoscopic stapler
through a port, the limitation in the angulations of currently available
staplers and the need for multiple firings are frequently quoted as being
limiting factors in allowing laparoscopic low rectal transection13,20,21. Pfannenstiel incisions have been used to overcome these
perceived problems13. An alternative approach adopted by
others is to use a supra-pubic port, hand-port22 or incision.
We have learnt through experience19 that it is possible in all but
the largest of tumours and narrowest of android pelvises to transect and staple
the gut tube low down at the level of the pelvic floor using an ATG45 (Ethicon
Endosurgery, Bracknell, UK) introduced from the right iliac fossa using two
anterior-posterior firings. The secret is in dissecting/defining the “gut
tube” and pelvic floor (optimized by using a 300 laparoscope) and
more importantly utilize the fulcrum effect of the port by placing the stapler with
a fully pronated forearm, flexed wrist and an internally rotated, abducted
shoulder. The linear cutter will flex and close at 900 if the
tip is pressed against a fixed structure i.e., pelvic side wall/sacrum, a fist
placed against the perineum; once the pressure is released it will “return” to
450 and allow firing. A Spackman uterine
retractor22 not only helps with the dissection, but also once
completed, keeps the vagina under tension and away from pouch anal anastomosis.
Although our 32% morbidity (early and late onset complications
plus readmissions) is on the high side, and is probably a reflection of the
complexity of the surgery (the comparable figure18 for segmental
resection in our unit is 22%), it is vey similar to that reported by others11,12,22,25. The DVT/PE occurred in a patient who went on to be diagnosed
as factor VLeiden deficiency. Dense impenetrable adhesions
necessitated early conversion in 7%, a rate similar to that reported by Kienle et al11 in their 50
patients. Surprisingly four of the
five conversions followed an initial laparoscopic colectomy. The Leeds group recently reported a 0%
conversion rate in 36 patients13. 51 of our (70%) patients had an uncomplicated recovery.
One of the
problems with open ileal pouch surgery is the high rate (23%) of adhesive
small-bowel obstruction (SBO); the cumulative risk of SBO in 1,178 patients has
been calculated at 8.7% at 30 days, 18% at 1 year, 27% at 5 years and 31% at 10
years26. In their case
note review27 of 276 patients followed for a median of 6.3 years,
the Oxford Group reported a readmission rate of 28% with 10% requiring
re-operation (43% within one year). The laparoscopic sub-set required less
adhesiolysis at second-stage surgery (0% vs. 36%, p < 0.0001) and had fewer
small bowel obstructive episodes within the first year (0% vs. 14%, p < 0.0001)
than open patients. This benefit was
translated into a potential financial saving of $1,832 per pouch constructed. LRPC with its reduced risk of adhesions may have
an important role in maintaining fertility; 71% of 34 female study patients were
found to have no adnexal adhesions at laparoscopy prior to ileostomy closure
and no patient had adhesions affecting both adenaxea)28. The one
late fatality in our present series and only case of small bowel obstruction
followed a small bowel mesenteric volvulus; the complete absence of any
adhesions, including the free edge of the mesentery of the afferent limb of the
pouch probably had a major role in its development.
Dunker’s comparative study7, in
which a midline wound was used for specimen extraction and pouch construction, failed
to demonstrate a significantly higher body image score compared with that
obtained following conventional surgery; cosmetic scores, however, were
significantly higher in the laparoscopic group. This small study showed no
difference in functional outcome and quality of life scores between the two
contrasting approaches to treatment. The Mayo group29 examined a
larger subset; 125 of 289 patients (43% responders) were questioned one year after
operation to evaluate sexual function, body image, and quality of life. There
were no significant differences in terms of demographics, complications, or
long-term functional outcomes between responders and those who did not. There
were no differences in results between laparoscopic and open patients using the
three survey instruments. Whilst orgasmic function scores were significantly lower
in men who underwent LRPC compared with open procedures, overall, sexual
function scores were equal to, or better than normal values for men but were
lower in women. Interestingly, overall body image and quality of life scores
were above the means published for the United States.
is important to know that morbidity following LRPC is low, it is perhaps more
reassuring that the adoption of laparoscopic restorative procto-colectomy has
not associated with adverse function (24hr and nocturnal frequency as well as
incontinence) and impaired quality of life. After all it is this endpoint that matters
to the patient in the long-term. It is contentious whether or not laparoscopic
rectal surgery itself is associated with a higher incidence of bladder and
sexual function compared with open surgery; 41% of CLASICC1 patients
reported a severe change in sexual function, compared to 26% in the open group
(not significant). The groups however were poorly matched and there were more
TMEs in the laparoscopic group. The Brisbane group30 report a more
appropriate 6% sexual dysfunction in 101 male patients; this falls to 2% when
the effect of radiotherapy is excluded.
Whilst the pelvic dissection is technically challenging, particularly
when mobilizing a fibrosed defunctioned rectal stump in a male with a narrowed
pelvis, the magnification does afford a superior view of the autonomic nerves,
particularly behind the seminal vesicles and a 300scope allows one to
“look around corners”. The main problem with laparoscopic TME is that it is
very easy to tent the hypogastric nerves by retracting in a cranial/lateral
direction, particularly so on the left hand side, and if the operator is
unaware of this difference from open surgery then it is very easy to enter the
presacral plane and damage or worse still divide the nerves. This effect is reduced if you do not
employ an assistant to hold and retract the recto-sigmoid cranially to the left
We have shown that laparoscopic restorative procto-colectomy
with ileo-anal pouch is technically feasible and can be performed without an
unduly lengthy operation or morbidity. More importantly, it is safe and
predictable with good functional outcomes that are comparable to open
techniques. However, the procedure
is difficult and technically demanding and requires lots of concentration. No
one should embark on LRPC unless they are adept at laparoscopic TME and
ultra-low rectal transection.
We acknowledge the following who have made
substantial contributions to the conduction of this work: Gareth Greenslade
(Anaesthetist), Fiona Bradden (Data Base) and the following Laparoscopic Fellows
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