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PATIENT SELECTION

Patients with either ulcerative colitis or indeterminate colitis are candidates for this procedure after total abdominal colectomy. Though some studies suggest select patients with Crohn’s disease may safely undergo this procedure, perianal Crohn’s disease and/or fecal incontinence are absolute contraindications.

PREOPERATIVE EVALUATION/PREPARATION

Prior to performing a restorative proctocolectomy with ileal J-pouch reconstruction, the patient should have normal nutrition and be marked by enterostomal therapy for possible ileostomy sites. A mechanical/oral antibiotic bowel prep is administered to lessen bowel gas, facilitate bowel manipulation, and reduce the risk of wound infection. Thromboembolism prophylaxis, either pharmacologic or mechanical, is started prior to induction of general anesthesia. Prophylactic antibiotics that cover intestinal flora are given within 1 hour prior to the skin incision. After induction of general anesthesia, an orogastric tube and urinary catheter are placed.

POSITIONING

A beanbag should be placed under the patient. The patient should be placed into a low lithotomy position with Allen stirrups. Each ankle, knee, and opposite shoulder should be aligned. No pressure should be placed on the peroneal nerves or calves. The angle between the thigh and the plane of the bed should be between 0 and 10 degrees. Any more flexion will limit range of motion for the instruments. Any more extension may lead to an anterior dislocation of the hip.

Each elbow (ulnar nerve) is covered with a gel pad, and both arms are carefully adducted. Care must be taken to avoid compromising or kinking the intravenous lines.

The beanbag is carefully cradled above both shoulders and around the arms to prevent the patient from falling while in extreme positioning. The air is suctioned from the beanbag so it retains that shape. Tape is placed under the bed, over each shoulder, and across to the other side of the bed. Care is taken to ensure that peak airway pressures are not inappropriately elevated, suggesting that the tape were too tight. Security of the patient on the table should be confirmed using maximal Trendelenburg positioning prior to draping.

DETAILS OF OPERATION

Mobilization of Colon

There are a number of critical steps for the laparoscopic mobilization of the entire colon. These include mobilization of the left colon, splenic flexure, transverse mesocolon, and right colon; division of the middle colic artery; division of the proximal rectum; and creation of an ileorectal anastomosis or end ileostomy. The ability to accomplish these tasks requires movement of the surgeon and assistant around the table as needed to optimize instrumentation. Surgeons vary in their preference of the order of performing the listed steps.

Trocar placement and details of left, right, and transverse colon and rectal resections have been described in detail in previous chapters.

After placement of the trocars, the surgeon and first assistant begin the ...

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