Restorative proctocolectomy & pouch

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Essential equipment:

  • two 5mm trocars (LIF & if necessary an additional suprapubic on R)
  • two 12mm trocars (umbilicus & ilesostomy site)
  • two 5mm 35cm fenestrated grasping forceps (Storz)
  • 5mm Harmonic scalpel
  • Medium 10mm (purple) Haem-o-Lock Clips
  • Two video monitors on both sides of the patient

Use gravity and the patients’ anatomy as much as possible and always use a 300 scope.

Start by standing on the patients Right, mobilise the distal SRA and undertake a nerve preserving TME down to the pelvic floor. Clip & divide the SRA. 

Divide the sigmoid mesocolon close to the bowel and continue to the splenic flexure.  Sideways tilt and head-up will help.

Mobilise the Gt. Omentum from the transverse colon (easier than removing it). Identify and divide the Middle Colic vessels between clips.  Watch out for the SMA!

Move to the pts left, reverse the tilt and mobilise the ascending colon, terminal ileum.  It is unnecessary to divide the ileocolic vessels at this stage.

It is usually possible to divide the distal rectum with an articulating ATGW 45 stapler (perineal pressure and downwards pressure form the stapler can help).  A pfannenstiel and TX30G is usually required in a man.

Deliver the specimen through the proposed ileostomy site.  Take your time and don' perforate the bowel!

 

or alternatively use a pfannenstiel incision, divide the ileocolic vessels then create your stapled 15cm J-pouch in the standard manner.  Insert and tie the staple gun head into the pouch.

Replace the pouch/small bowel and take care not to rotate the distal mesentery.

Construct a stapled pouch anal anastomosis watching out for the vaginal in females.

Defunction with a loop ileostomy.


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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
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