Ultra-low TME Coloanal J Pouch

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Essential equipment:













  • Two 5mm, one 12mm disposable trocars
  • Two 5mm fenestrated Johan grasping forceps 
  • 5mm Harmonic scalpel  
  • Medium (purple) Haem-o-Loc Clips 
  • Harmonic or Ligasure
  • Electric operating table
  • LoneStar retractor or PPH (03) CAD 

We use gravity as much as possible (200steep head down and slight right lateral tilt).  A warming blanket and catheterisation (remove at end of procedure) are essential.  There should be minimal hip flexion.  We always use a 300 scope.

In the case of a female patient with a uterus in situ,insert a Sprakman retractor after having dilated the cervix.  This is the best way to elevate the uterus out of the pelvis.

Site the laparoscopy port approx. 3cm above/lateral to the umbilicus in a "short" abdomen (short distance from umbilicus to the symphysis pubis) or a mass is palpable or as in most cases, through the umbilical tube.  Insert the higher 5mm port where the covering ileostomy is to be sited.  

Use a medial or lateral approach as findings dictate – if there is very little space/too much small bowel/very large tumour/sigmoid diverticulitis we would always start the dissection laterally.  DO NOT GET FIXED ON ONE APPROACH as it will limit what you can do. 
  
The first landmark in dissection of the IMA is the sacral prominentry; opening the peritoneum here medial to the left ureter correctly exposes the neuro/vascular elements of the mesentery.  Remember, it is easy to dissect behind the hypogastric nerves. 

When dissecting behind the sigmoid mesentery, watch out for the gonadal vein as much as the ureter.  If you make a hole in it reduce the venous pressure with steep head down tilt and clip it.  Apply 3 Haem-o-Lok clips to the origin of the IMA and divide with Harmonic (leaving two on the IMA base).

Retract the IMV forward and to the left dividing attachments to the DJ flexure.  Identify the origin and the inferior border of the pancreas.  Mobilise the mesocolon off the retroperitoneum.  Don't stray in and out of Gerota's fascia; keep in front of it!  Once the colon has been mobilised off the kidney, clip and ligate the IMV at its origin (3 clips again).  

The medial approach to the splenic flexure uses an initial dissection, after division of the IM vein through the transverse mesocolon to allow entery into the lesser sac.  The next step is to divide the posterior attachments of the transverse mesocolon at the lower border of the pancreas.  Potential dangers include; dissecting behind the pancreas (don't follow the IMV too far and make the hole through the TV mesocolon early).  Do not mistake the splenic vein for the IMV and don't stray into the mesentery and damage the marginal vessels.  It is rare to damage the spleen; you only really see it when you dissect the lateral peritoneal attachments.

The lateral approach is the same as in open surgery ie mobilised off Gerota's fascia.  As in open surgery it sometimes helpful to first mobilise the omentum from the transverse colon.
Open the lesser sac or mobilise the Gt. Omentum to allow easier resection of retroperitoneal attachments of the splenic flexure.  

Retract the rectum upward and forward, identify the loose areolar plane between the mesorectum and the presacral fascia (with the hypogastric nerves lying on it).  The right and left nerves should now be clearly visualised on the presacral fascia.  Divide the mesorectum with the harmonic scalpel using "slow burn" and the active tip away from the bowel. 
 

Insert and suture the CAD or alternatively (as shown) use a LoneStar retractor.  Divide the rectum at the level of the dentate line with a hand held diathermy to enter the intersphincteric plane.  Oversew the divided bowel before "joining-up" with the dissection from above.  Deliver the rectum and sigmoid colon through the anal canal (see below) after removing the CAD.






Choose a suitable segment of descending colon to form the colo-pouch.  Feel for the pulsation in the marginal artery; felt between left forefinger and thumb (shown below). Check that the venous drainage is intact.  Divide the marginal artery using two Hem-o-Loc clips.




Divide the colon with a linear stapler.



Create the colo-pouch with a further firing.



Reduce the colo-pouch without twisting the bowel.  Replace the CAD (if used) and then suture the colo-pouch to the anal canal.  Although not shown here, the CAD makes this VERY EASY.






Place a 16 Robinson's drain through the lower 5mm port and direct into the pre-sacral space.  Grasp the terminal ileum with the Johan forceps before proceeding to form 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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