Laparoscopic total abdominal colectomy (TAC) entails the removal of the entire colon up to the top of the rectum. Intestinal continuity may be restored in the form of ileorectal anastomosis or an end ileostomy may be fashioned depending on the indication for surgery, patient’s general condition, and condition of the colon and the rectum. TAC is the procedure of choice for patients who are acutely ill from pancolitis due to ulcerative colitis, Crohn’s disease, or Clostridium difficile colitis; for patients who have severe colonic bleeding without accurate preoperative localization or obstructing left colon cancer with evidence of perforation; or ischemia in the right colon. In these situations, it is performed urgently. Electively, TAC can also be performed for colonic dysmotility, cases of synchronous colon cancer, selected patients with inflammatory bowel disease, and colon polyposis syndrome patients who are candidates for ileorectal anastomosis.
This operative description is for chronic ulcerative colitis, or Stage I procedure.
Patients with chronic ulcerative colitis are most likely on chronic steroids. Patients who are taking steroids preoperatively should be given a stress dose of Hydrocortisone 50–100 mg IV in the perioperative area before surgery. Postoperatively, the steroids should be weaned depending on the preoperative dose, and the duration of use.
Preoperative marking with the enterostomal nurse is essential to ensure the best position for a planned stoma, and to avoid issues related to inappropriate positioning.
Use the modified lithotomy position.
Four Ports Diamond-Shaped Configuration (Figure 12-1)
This configuration will allow you to do the total abdominal colectomy and work in all the abdominal quadrants.
A supraumbilical port (12 mm) is used for the camera.
Two 5-mm ports are placed in the suprapubic area and the left lower quadrant (LLQ).
Right lower quadrant (RLQ) port: This port can be placed through the planned stoma site, if appropriate. Make a circular incision at the planned stoma site. Deepen the incision and continue with the dissection around the skin and subcutaneous fat in a cylindrical shape until the fascia is reached. Then the fat can be amputated and discarded. Now, the fascia should be visible. This technique can be used if the abdominal wall is thick, and this would help with delivering the stoma at the end of the case and mature it. If the abdominal wall is thin, then after making the circular skin incision, place the 12-mm trocar in the usual fashion. This incision will not need to be closed, since it will be the future stoma site and this by default will be enlarged. The caveat is that the site of this trocar may not be the usual typical location of the ...