Abstract
Abstract
Introduction:
After its description in 1980, restorative proctocolectomy has become the procedure of choice for ulcerative colitis (UC). The supposed advantages of the laparoscopy have proven beneficial for colorectal operations but a standard technique in laparoscopic restorative proctocolectomy (LRP) is still lacking. In this study, we present our technique of LRP with vascular high ligation (VHL) and embryological dissection (ED).
Materials and Methods:
This retrospective study reviewed patients who underwent LRP with VHL for UC from January 2009 to June 2015. Of these, only two-stage LRP patients were included to the study. The LRP technique was performed by five ports through a medial-to-lateral approach. The dissection was carried out between the embryological planes and all the vessel roots were highly divided. A diverting ileostomy was performed in all of the patients.
Results:
Forty-six patients were operated for UC with the laparoscopic approach. Among these patients, there were 19 (8 females) patients who were performed LRP with VHL. The median age was 42 (range 25–62) years. No intraoperative complications occurred. There was no conversion to open procedure. Early postoperative complications were observed in 3 (15.8%) patients, including postoperative mechanical bowel obstruction (n = 1), wound infection (n = 1), and ileal pouch bleeding (n = 1).
Discussion:
High ligation of the vessels is not routinely performed except in the presence of malignancy. In our study, we focus on the importance of high ligation and ED for better observation and preservation of the important anatomical structures. According to our opinion, this approach aids in the preservation of the ureters, nerves, and the duodenum providing better observation of dissection planes.
Introduction
I
During laparoscopic restorative proctocolectomy (LRP), we have noticed that clearer surgical field provided by performing VHL and embryological dissection (ED) with mesocolic/rectal dissection increases the observation of the retroperitoneal structures, especially in the presence of severe pericolonic inflammation.
Besides, although with very small incidence, by this technique any incidental colorectal cancer could be treated at the same surgical session without a need for further lymphadenectomy. 2
In this study, we present our experience with VHL and ED techniques in LRP for UC.
Materials and Methods
This retrospective study comprised patients with UC who underwent LRP and ED between January 2009 and June 2015. Patients before 2009 were not included since before that year we were performing classical LRP without VHL. A shift to VHL took place in the beginning of 2009. Among these patients, only two-stage (first stage: laparoscopic total proctocolectomy with J-pouch and pouch-anal anastomosis with diverting loop ileostomy; second stage: closure of loop ileostomy) LRP procedures were enrolled to the study. All patients who underwent procedures other than two-stage laparoscopies were excluded from the study. The medical records of all patients were retrieved from the patients' files. Patient demographics, body mass index (BMI), preoperative duration of disease, operation time, blood loss, and complications were collected.
Surgical technique
The surgical procedure is performed through a medial-to-lateral approach with standard laparoscopic instruments through five ports. Our technique has been described in a previous article. 3 The dissection starts at the ileocolic vessels that are clipped and transected at their origin. Staying between the embryological planes just anterior to the right ureter, Gerota's fascia, and duodenum, mesenteric dissection is extended up to the root of the right colic artery (if present) and the middle colic artery, which are transected between clips near the superior mesenteric artery. After mobilization of the right colon laterally, the terminal ileum is prepared and transected with an endoscopic linear staple. With traction on the transverse colon, the hepatic flexure is freed, the lesser sac entered, and then the gastrocolic ligament divided. The dissection is continued along the transverse mesocolon, taking down the splenic flexure. Position of the patient and the surgical team was changed. On the left side, the peritoneum is incised at the sacral promontorium and the aortomesenteric window is opened, preserving the left ureter, gonadal vessels, and autonomic nerves. Again the surgical procedure continues superficial to the Gerota's fascia. The inferior mesenteric vessels are clipped and divided. After lateral mobilization of the left colon, total mesorectal excision follows in the holy plane. Then, the rectum is transected with an endoscopic linear staple. The specimen is extracted through a suprapubic incision by enlarging of the suprapubic trocar site. Creation of ileal pouch, stapled pouch-anal anastomosis, and planned diverting loop ileostomy completes the operation.
After the operation, starting on postoperative day 1, patients were asked to ambulate and to perform breathing exercises, and the urinary catheter was removed. In addition, patients who could tolerate liquids on postoperative day 1 were offered solid food. Discharge criteria were tolerance of meals without nausea or vomiting, established stoma function, adequate pain control with oral analgesia, and independent ambulation.
Results
Between January 2009 and June 2015, 46 cases of UC underwent restorative proctocolectomy, of which 28 were performed laparoscopic, 17 open, and one robotic restorative proctocolectomy. Of the 28 laparoscopic patients, 19 (8 females) underwent two-stage operations. Indications for surgery were intractability to or complications of medical therapy in 18 (95%) and synchronous right colon cancer in one (5%) of the patients. The median age was 42 (range 25–62) years with an average UC duration of 5 (range 1–18) years. The mean BMI was 23 (range 16–34) kg/m2. The mean operative time was 344 ± 71 minutes (mean ± standard deviation) and the mean operative blood loss was 137 mL (range 40–600). There was no conversion to open procedure. No intraoperative complications occurred. Median follow-up period was 4 (range 1–7) years. Early postoperative complications were observed in 3 (15.8%) patients, including postoperative mechanical bowel obstruction (n = 1), wound infection (n = 1), and luminal pouch bleeding (n = 1). All surgical complications were treated conservatively. There was no mortality.
Discussion
Since January 2009, our LRP technique for UC had changed from classical near-colonic dissection to VHL and ED. According to our limited experience, LRP with VHL of the mesenteric vessels and ED with mesocolic/rectal dissection for UC are feasible and can be performed with good technical efficiency. With increasing experience in laparoscopic colorectal surgery for cancer, we have begun performing VHL and ED for UC patients. It was our subjective experience that this approach provided clearer ED planes and better surgical anatomy.
In patients with UC undergoing LRP, the mesocolon is usually divided in a plane near the bowel wall to avoid injuries to the retroperitoneal structures such as the ureters, gonadal vessels, duodenum, and autonomic nerves. 4 However, dissection in this plane requires ligation of many mesenteric vascular branches and may sometimes be difficult in the presence of chronic pericolonic inflammation. 1 This may bring some risks of harm to the underlying structures.
In our series, there was no mortality and no conversion to open procedure. Overall complication rate was 15.8%, which was comparable to the complication rates reported in the literature. 5
Dissection between embryological planes causes minor blood loss and less tissue trauma. In addition, dissection under direct vision of the retroperitoneal structures may ease their preservation. Moreover, dissection close to the bowel wall may leave some microabscesses within the mesocolon in active colitis. Further studies comparing the technique mentioned and the classical technique are necessary to confirm these hypotheses.
Our technique could be criticized as being an overtreatment for a “benign” disease because the dissection carried out close to the vascular pedicles could damage the autonomic nerves. 4 Since the internal anal sphincter receives excitatory innervation from the thoracolumbar sympathetic nerves, damage to the lower mesenteric ganglion and origin of the thoracolumbar plexus could cause alteration in the internal sphincter function. 6 In our series, we did not encounter any injuries to the autonomic nerves.
The main limitation of our study was its retrospective character. Another criticism of our approach might be that in expense of better observation, it may cause longer operating times and major vascular and autonomic nerve injury due to close dissection. 7 In our opinion, VHL and ED by increasing the observation ease preservation of the retroperitoneal structures such as nerves, ureters, and the retroperitoneal vessels.
The operating time spent during the dissection between the embryological planes in our technique could be similar to the time-consuming near-colonic mesenteric dissection in the classical technique. Comparative studies may clarify these concerns.
In a study reported by Remzi et al., the incidence of coexisting colorectal cancer in UC patients was nearly 4%. Of these patients, 10% were incidentally diagnosed. 8 This information could bring a question in mind about the benefit of complete mesocolic surgery for a disease with 0.4% incidental colorectal carcinoma. To advise a routine VHL in LRP with this incidence rate is open to discussion. In our series, we did not face any incidental colorectal carcinoma.
Future studies comparing ours and the standard approaches regarding the operating time, blood loss, complications, sexual function, and hospital stay may make it clear whether the presented technique has advantages or not.
Conclusions
LRP with VHL and dissection through the embryological planes can be successfully performed with satisfactory outcomes to treat UC. According to our opinion, providing better observation of dissection planes, this approach aids in the preservation of the retroperitoneal structures. Further comparative studies are required before the VHL and ED techniques can be recommended as a regular approach in LRP for UC.
Footnotes
Acknowledgment
The authors gratefully acknowledge the assistance of Ebru Kirbiyik in data collection for the preparation of this article.
Disclosure Statement
No competing financial interests exist.