Ileostomies, Colostomies, Pouches, and Anastomoses

Total proctocolectomy with permanent end ileostomy is curative for patients with UC and returns most patients to excellent health while removing premalignant colonic mucosa in patients with UC or familial adenomatous polyposis (FAP). Improvements in surgical techniques and a better understanding of stoma physiology along with better stoma appliances and improved patient education have eliminated many of the dangers and disadvantages previously associated with an ileostomy.

Frequent mechanical complications secondary to ileostomy dysfunction (e.g., partial obstruction) as well as the metabolic consequences of ileal stomas, became apparent in the 1940s when ileostomies were increasingly being constructed. Before advances in postoperative fluid and electrolyte management and development of newer techniques in ileostomy construction, ileostomies were created by exteriorizing the intestine through the abdominal wall and suturing the serosal surface of ileum to the skin. Exposure of the ileal serosa to the alkaline stomal effluent frequently resulted in serositis and ileostomy dysfunction. The solution to this problem was to evert the full thickness of the exteriorized ileum and to suture its mucosa to the adjacent dermis. This technique of ileostomy eversion was described in 1952 by Bryan Brooke in the United Kingdom, and this ileostomy is commonly referred to as a Brooke ileostomy ( Fig. 117.1 ). Patients’ resistance to having an ileostomy has been in large measure alleviated by emphasizing the beneficial aspects of this operation (e.g., curing the UC), as well as by the development of new stoma appliances that have led to excellent long-term results. The introduction of enterostomal therapy as an additional allied health field and the development of stomal support societies have provided significant support to patients with stomas.

Brooke ileostomies are incontinent, a problem that led the Swedish surgeon Nils Kock to develop the first continent ileostomy in 1969. The Kock pouch procedure featured an ileal pouch, a nipple valve, and an ileal conduit that led to a cutaneous stoma ( Fig. 117.2 ). Given that this was a continent stoma and that no appliance was necessary, it could be created flush with the skin. In the 1980s, the Kock pouch was used in selected patients with UC and FAP, but enthusiasm for this operation was tempered by the frequent occurrence of complications, such as slippage of the nipple-valve.

Driven by the overall poor acceptance by patients of ileostomies and the ever-present external appliance, surgeons explored other alternatives to the incontinent Brooke ileostomy. The straight ileoanal pull-through operation, which was used primarily in children for the surgical treatment of Hirschsprung disease, was considered as an option for patients who required proctocolectomy. This operation was plagued with excessive liquid bowel movements and was undesirable for adult patients who long suffered from UC. Therefore, an important technical modification was proposed: creation of an ileal reservoir (pouch) to reduce the frequency of daily bowel activity. This operation preserves the function of the anal sphincter complex and allows for the normal, albeit more frequent, exit of feces via the anal canal. Because of increasing experience with this operation over the last 3 decades, the ileal pouch-anal anastomosis (IPAA) is now the procedure of choice in most patients who require proctocolectomy for UC or FAP.

This chapter describes the pathophysiologic and clinical implications of colectomy and reviews the options and alternatives for the control of enteric output. Three surgical options are currently available to patients with chronic UC and FAP: total proctocolectomy with the end-Brooke ileostomy, total proctocolectomy with IPAA, and ileoproctostomy (i.e., ileorectal anastomosis [IRA]). Both the Kock pouch and IPAA are contraindicated in patients with Crohn disease (CD), for whom segmental colectomy remains a viable option.

Configuration of An Ileostomy

Small bowel stomas can be used for temporary or permanent fecal diversion. Small bowel end stomas are typically easy to create owing to the mobility of the robustly collateralized small bowel mesentery. These can be created by either laparoscopic or open abdominal approach. Once a sufficient length of ileum is exteriorized, it is assessed for tension, viability, mesenteric bleeding, and proper mesenteric orientation. It is then folded upon itself and sutured to the dermis, ideally protruding 2 to 3 cm above the skin (See Fig 117.1 ). This maneuver is necessary to cover and protect the eviscerated ileal serosa with mucosa, shielding it from caustic bowel effluent; it is performed with “Brooke” sutures that incorporate the full thickness of the cut edge of the ileum, a seromuscular “bite” of the more proximal ileum, and finally the dermis, which helps evert the mucosa. This also improves the sealing of the stoma appliance to the skin and decreases complications. The process of suturing the intestine (small or large intestine) to the dermal skin is known as “maturation,” or “maturing the stoma.”

Configuration of A Colostomy

Creation of a colostomy may be indicated in a variety of benign and malignant diseases for fecal diversion. The redundant, non-peritonealized transverse and sigmoid colon make them suitable options for loop colostomies. Transverse colostomies have a higher incidence of complications including prolapse as well as pouching difficulties. The stoma is usually protruded and everted about 1 to 2 cm. Due to the non-caustic nature of colonic effluent in contrast to ileal secretion, stoma eversion is not absolutely necessary, but may be considered for improved pouching.

Continent Ileostomy (Kock Pouch)

Clearly, one of the major (social) drawbacks to ileostomy could be eliminated if a continent stoma were possible. Nils Kock postulated that a pouch and nipple valve constructed of terminal ileum could store ileal content internally until emptied voluntarily by the patient via a large, soft catheter passed into the pouch several times daily, thereby obviating the need for an external appliance (see Fig. 117.2 ). In between catheter aspirations, the patient would simply cover the stomal opening with a Band-Aid. The first Kock pouch operation was reported in 1969, and the results were promising; however, the nipple valve sometimes failed, usually because it slipped out of the pouch, thereby resulting in incontinence. Techniques gradually improved, and the most recent approaches have been more successful, providing continence in most patients. In 2 series, more than 90% of patients were continent for both gas and feces, never requiring an appliance.

The high success rate of the Kock pouch, however, is achieved at the price of additional operations in most patients for nipple slippage or pouch dysfunction, fistula, or stricture. Wasmuth and colleagues reported a 50% rate of reoperation by 14 years after continent ileostomy construction. Furthermore, in a series of 96 patients with continent ileostomy reported by Lepisto, 24% of patients required conversion to a conventional stoma and 59% required reoperation, with a total of 85 pouch reconstructions being performed: 42 patients had one reconstruction, 9 had 2 reconstructions, 3 had 3 reconstructions, one had 4 reconstructions, and 2 had 6 reconstructions. Others authors have reported similar findings: patients generally did well after initial continent ileostomy construction, but a sizable minority required repeated surgical intervention either to salvage pouch function or remove the pouch.

Despite requiring numerous reoperations, most Kock pouch patients are satisfied with the outcomes of their functioning pouch. In a recent comparative study of quality of life (QoL) in patients with standard ileostomies, ileal pouch, and Kock pouch, the Kock pouch patients did not fare significantly better or worse than those with a conventional ileostomy or IPAA; 56% of the continent ileostomy patients, however, did require reoperation to maintain function of their ileostomy.

Patients’ enthusiasm for the Kock pouch procedure is quite surprising given the numerous and frequent complications, which often require major surgical intervention. The Barnett Continent Ileostomy Reservoir was designed to reduce the incidence of valve slippage and fistula formation, however, no controlled data exist to suggest that this modification is superior to the original Kock pouch procedure. Another continent ileostomy, the T-pouch, has been developed, also to combat the problem of nipple valve slippage. In the T-pouch, the valve mechanism is made by securing an isolated distal ileal segment into a serosal-lined trough formed by the base of 2 adjacent ileal segments. The high-volume/low-pressure reservoir is fashioned around this isolated valve segment. Once constructed, the distal end of the valve mechanism is brought up through the skin as a stoma. T-pouches have been constructed in only a few patients and the results are promising, but long-term follow-up studies to assess the structural integrity and clinical success of the new valve design are lacking. Given the success of the IPAA operation, continent ileostomy operations are rarely performed in modern-day surgical practice and are reserved for the few patients who desire enteric continence, whose Brook ileostomy has failed following a proctocolectomy, and for those individuals who are not candidates for IPAA because of rectal cancer or poor anal sphincter function. A patient who desires continence and whose occupation may preclude frequent visits to the toilet also may be a candidate for a continent ileostomy.

Before performance of a continent ileostomy operation, exclusion of CD is mandatory (see Chapter 115 ). A careful discussion with the patient must exclude a prior history of small bowel resection, perianal or perirectal abscesses. A detailed anorectal examination also must exclude the presence of fistula-in-ano. Construction of a continent ileostomy is contraindicated when CD is suspected, as future intestinal resections may render the patient susceptible to short bowel syndrome and dependent on parenteral nutrition.

Anastomotic Dehiscence and The Ghost Ileostomy

Anastomotic dehiscence is one of the most dreaded complications in colorectal surgery with rates ranging from 3% to 21%. Multiple risk factors have been associated with anastomotic failure and include disease factors, patient factors, and surgeon factors. Increasingly, the role of the patient’s microbiome and stress response to surgical trauma is being defined in the occurrence of anastomotic leaks. Alverdy and colleagues have suggested that a patient’s microbiome and its response to surgery and an anastomosis may play a vital role in the healing of the anastomosis.

Several studies have concluded that colorectal surgical procedures performed by surgeons with specific post-graduate fellowship training in colorectal surgery compared with non-colorectal surgeons or high-volume abdominal surgeons carry a lower risk of anastomotic complications, overall complications, and mortality.

Patients at high risk of anastomotic failure are considered for fecal diversion (usually a loop ileostomy) to protect them from the subsequent septic complications of anastomotic leakage and pelvic sepsis. The decision to perform fecal diversion during pelvic surgery can be challenging and controversial. Moreover, determining which patients benefit from fecal diversion is not straightforward. The risk of developing an anastomotic leak must be carefully weighed against the risks of bearing an ostomy for a period of time and the physiologic and psychosocial discomfort that is associated with an ileostomy. Furthermore, stoma closure and restoration of intestinal continuity represents another operation, an additional hospitalization with its own costs, and the potential for other complications.

In 2007, Sacchi et al. described the term “virtual ileostomy,” which was later termed “ghost ileostomy.” Creation of a ghost ileostomy may be considered when the anastomosis is at a higher than normal risk of leakage, but performance of an ileostomy may not ultimately be necessary. This technique can be useful in such circumstances. To create a ghost ileostomy, a vessel loop, which is a soft silicone rubber band, is passed under the last segment of the terminal ileum about 20 cm from the ileocecal valve and exteriorized through a small stab incision at the site of the possible ileostomy if needed. The vessel loop is sutured to the skin avoiding any traction or kinking of the small bowel. In the case of an anastomotic breakdown, a small incision is made around the site and the loop of bowel is pulled up creating an ileostomy, thereby avoiding more extensive surgery. If not needed, the vessel loop can easily be removed in the office at the 2-week follow up visit.

It should be emphasized that fecal diversion does not reduce the incidence of anastomotic leaks; it merely militates against the untoward clinical consequences of pelvic sepsis. Creation of a ghost ileostomy also does not prevent anastomotic dehiscence, but reduces unnecessary stomas and their negative consequences. It is also safe and easy to accomplish at the end of an operation.

Ileal Pouch-Anal Anastomosis

IPAA is now the procedure of choice for most patients who require proctocolectomy for UC or FAP. IPAA is not considered suitable for patients with CD, although this recommendation is being reevaluated. An ileal pouch has several major advantages: nearly all mucosal disease is removed—in contrast to IRA, in which all of the rectal mucosa remains intact and is at continued risk for inflammation and cancer; the normal route for fecal elimination is maintained, and a permanent stoma is not required; and the anal sphincters are not removed.

In 1947, Ravitch and Sabiston first described ileoanal anastomosis, an operation that was adapted by the success of pediatric surgeons who used it in children with Hirschsprung disease. Initially, the operation was performed as a straight pull-through procedure, and the terminal ileum was sutured directly to the anal verge. Although results in children were encouraging, excessive stool frequency and anal seepage were unacceptable sequelae to many adult patients. Subsequently, the operation was modified to include one of several forms of an ileal pouch. The basic surgical steps are as follows: a proctocolectomy is performed; the distal rectum is divided at the top of the anal canal at the anorectal ring, which leaves a small cuff of residual rectal mucosa and all of the anal canal mucosa intact; an ileal pouch is fashioned from the terminal 15 to 20 cm of ileum and then stapled or sutured to the cuff of remaining rectal and anal canal tissue. If a hand-sewn technique is used, a mucosal proctectomy is performed to remove all (or nearly all) of the mucosa to allow for an anastomosis between the mucosa of the ileal pouch and the dentate line. A diverting ileostomy usually is required for 2 or 3 months until the anastomosis heals completely. At a second operation 8 to 12 weeks later, the diverting ileostomy is closed. Although pouches of different configurations have been advocated by various surgical groups in the past, the pouch routinely used today is the J-pouch because of relative ease of construction and reliable function ( Fig. 117.3 ).

Fig. 117.3, The anatomy of the most commonly used type of ileal pouch, the J-pouch. A pouch approximately 12 to 15 cm long is constructed by opening the common wall between the 2 limbs of the J formed from the distal terminal ileum. The apex is then anastomosed to the upper anal canal.

Clinical Results

Following IPAA, many centers report patients having an average stool frequency of 6 stools during the day and one stool at night. Daytime and nocturnal stool frequency and the ability to discriminate flatus from stool remain relatively stable over time, whereas the need for stool bulking and hypomotility agents declines. The lower stool frequencies 6 months after surgery, compared with the frequency in the early postoperative period, are likely attributable to a “settling in” of the pouch in the pelvis, increased pouch capacity, and pouch adaptation to the ileal effluent load over time, as well as mucosal adaptation to the ileal load.

In a series from the Mayo Clinic, major fecal incontinence (more than twice per week) occurs in 5% or less of patients during the day and 12% of patients during sleep. In contrast, minor episodes of nocturnal incontinence (e.g., seepage) occur in up to 30% of patients one year after the operation. A pad must be worn by 28% of patients for protection against seepage. Minor perianal skin irritation is reported by two thirds of patients. Patients older than 50 years of age have a higher daytime stool frequency (8/day) than younger patients (6/day). Men and women have similar stool frequencies postoperatively, but women have more episodes of fecal soilage during the day and night; this occurrence is thought to be related to a shorter average anal canal length in women. Of patients with minor incontinence at one year, 40% remain unchanged, 40% improve, and 20% worsen by 10 years. Nocturnal fecal spotting increases only marginally during the 10-year period. These results are corroborated by a prospective observational study examining 391 patients who underwent an IPAA operation and were followed for a mean of 33 months. The authors found that the majority of patients were fully continent, had an average of 6 bowel movements per day, and were able to defer a bowel movement until convenient. Mild fecal incontinence, when observed in this study, improved over time.

Controversies

Double-Stapled Versus Hand-Sewn Anastomosis

The controversy over whether anastomosis of the ileal pouch to the anal canal should be performed with a double-stapled technique or hand-sewn technique revolves around functional outcomes related to preservation of the anal transition zone (ATZ) mucosa. In non-randomized trials, a stapled anastomosis has been equated with better outcomes because of reduced stretch injury (dilation) to the anal sphincters, preservation of the ATZ and thus improved anal sensory discrimination, maintenance of the rectoanal inhibitory reflex, and improved nocturnal continence. In a randomized prospective study that compared the double-stapled IPAA (17 patients) to the hand-sewn technique (15 patients), Haray and colleagues identified that stool frequency and incidence of daytime and nighttime fecal incontinence were similar in the 2 groups. In the stapled cohort, 1.5 to 2.0 cm of ATZ was preserved, whereas complete mucosectomy was performed in the hand-sewn group. The overall complication rates were the same in the 2 groups; however, fewer patients treated with the double-stapled technique experienced nocturnal incontinence.

Similar findings have been reported by other groups. In a meta-analysis of over 4000 patients, Silvestri and colleagues concluded that both techniques had similar early postoperative outcomes; stapled IPAA offered improved nocturnal continence, however, which was reflected in higher anorectal resting pressures as well as anal squeeze pressures.

Role of Defunctioning Ileostomy

The most feared complication of IPAA is anastomotic failure and pelvic sepsis. Therefore, after pouch construction, a defunctioning (diverting) ileostomy usually is performed to divert ileal contents from the pouch and promote healing. The reported rate of pelvic sepsis after IPAA ranges from 0% to 25%. In the series from the Mayo Clinic, the incidence of pelvic sepsis was relatively low (6%); however, when it occurred, it was responsible for a significant proportion of pouch failure. Ogunbiyi and colleagues identified pelvic sepsis as a major predictor of pouch failure in 27 patients who underwent IPAA salvage surgery, which accounted for 58% of pouch excisions.

Proponents of diverting ileostomy argue that the diverting stoma allows the pouch to fully heal and “settle” in the pelvis prior to use. Creation of a loop ileostomy does not completely protect the patient from pelvic sepsis; however, its presence minimizes the adverse clinical sequelae of a leak and eases the management of a patient with this complication. Supporters of a one-stage procedure (total proctocolectomy and IPAA without a diverting ileostomy) believe that an IPAA can be performed without increased risk of pelvic sepsis. A one-stage procedure avoids an ileostomy and a second hospitalization and operation, lowers the total cost, and results in a shorter hospital stay and perhaps in a decreased incidence of small bowel obstruction.

In the large single-surgeon study reported by Sugerman and associates, there were no differences in the complication rates and functional outcomes of patients who did not have a diverting ileostomy compared with those who had a diverting ileostomy; there also was no relationship to glucocorticoid use. Whereas there might be no significant difference in the complication rate in patients without a defunctioning ileostomy, Williamson and colleagues suggested that the severity of complications was greater in patients without a protecting ileostomy.

Although it is our practice to perform a diverting ileostomy in all patients undergoing IPAA, in properly selected patients who have an uncomplicated procedure performed by experienced surgeons, a one-stage IPAA might be appropriate; however, one-stage procedures are less frequently performed with the increased use of biologic therapies in UC (see later in section “Impact of Biological Medical Therapy”). The surgeon and patient care team must be attentive to the early signs of pelvic sepsis, aggressively investigate the possibility of a pouch leak, and intervene expeditiously when necessary.

Fertility and Pregnancy

Many women with UC are in their childbearing years, and so it is important that women be informed of and consider the effect of IPAA on fertility and pregnancy when surgery for their UC becomes necessary. Most of the relevant literature demonstrates a negative effect of IPAA on fertility, and pregnancy may be at least 5 times less likely to occur compared with the general population. In a meta-analysis by Rajaratnam and colleagues, a statistically significant increase of 3.91 in the relative risk of infertility was demonstrated after IPAA surgery. A number of studies have evaluated fertility and the course of a subsequent pregnancy after surgery. Patients who have had a proctocolectomy and end-ileostomy or Kock pouch can expect to have a normal pregnancy and delivery. In patients with IPAA who are pregnant, there is a slight increase in stool frequency, incontinence, and pad use is reported during the pregnancy. Fortunately, this is temporary, and patients return to their baseline pouch function after the pregnancy. There is a reported higher rate of cesarean sections in IPAA patients, but there appears to be no contraindication to vaginal delivery, and the decision to proceed to a cesarean section should be based upon obstetric considerations.

Previous studies evaluated the course of pregnancies after IPAA, but the specific issue of fecundity after IPAA had not been considered until 1999, when a Swedish population-based study demonstrated a significant reduction in fecundity after IPAA. More importantly, of the post-IPAA patients who became pregnant, 29% of pregnancies occurred only after in vitro fertilization (IVF) compared with the expected 1% of all pregnancies in Sweden during the study period. The cause of this decreased fertility is unknown, but the authors hypothesized that changes in pelvic anatomy resulting from removal of the rectum and dense adhesions from the pelvic dissection that resulted in scarring of the ovaries and fallopian tubes were major contributors to the problem (“trapped” ovary syndrome). Various techniques have been attempted to reduce the effect of surgery on ovarian and tubal function. Interposition of an omental pedicle graft or placement of adhesion barrier products, such as Seprafilm (Genzyme Corporation, Cambridge, Mass.), may help reduce adhesions and thereby keep the ovaries out of the pelvis yet in close proximity to the fallopian tubes. Oophoropexy, a procedure involving suturing the ovaries to the pelvic brim, also has been attempted, but may complicate the retrieval of the ova if IVF subsequently becomes necessary.

A case-controlled study comparing women with IPAAs and female controls who had previous abdominal surgery found that women who had an IPAA had significantly more infertility evaluations and need for infertility treatments. Analysis of infertility treatments for post-IPAA women demonstrated that they suffered a reduction in the probability of conception rather than complete infertility. This reduction in fecundity is not seen in women who have undergone IRA for FAP, which further the supports the idea that postoperative adhesions or altered pelvic anatomy contribute to this problem.

Given the growing evidence that IPAA reduces a woman’s fecundity, women need to be counseled regarding this prospect during the informed consent process before IPAA. If this is a major concern in a young woman suffering from medically refractory UC, a subtotal colectomy and ileostomy to control the disease without disturbing the pelvic anatomy may be offered, with a planned completion proctectomy and IPAA after childbearing is completed. In rare circumstances, total abdominal colectomy with IRA may be chosen until childbearing is complete.

Patients with IPAA who wish to conceive postoperatively should be referred to a fertility specialist if their attempts at conception are not successful. The most common treatments in patients with IPAA who desire pregnancy are clomiphene and IVF. Olsen and colleagues compared the expected pregnancy and birth rates of a cohort of women with UC to age-matched women without UC in Sweden. There was no difference in the expected birth rate in women from the onset of UC to the time of proctocolectomy. However, there was a significant reduction of births after IPAA. More importantly, in the post-IPAA patients who became pregnant, 29% of pregnancies occurred after IVF compared with the expected 1% of all births in Sweden. Success rates in fertility treatments are difficult to compare, given the variations between studies and fertility programs. Further investigations are necessary to determine the true success rates of fertility treatments following IPAA.

Ileal Pouch-Anal Anastomosis and Indeterminate Colitis

Among 1519 consecutive patients with UC undergoing IPAA between January 1981 and December 1995, 82 patients (5%) had features of indeterminate colitis, including unusual distribution of inflammation, deep linear ulcers, neural proliferation, transmural inflammation, fissures, and creeping fat. In a study from the Mayo Clinic, 12 (15%) of the 82 patients with indeterminate colitis eventually developed CD during follow-up, compared with only 26 (2%) of 1437 patients diagnosed with UC. The probability of remaining free of CD at 10 years was 98% in patients with UC and 81% in the indeterminate colitis patients. After IPAA, patients with indeterminate colitis who did not develop CD experienced long-term outcomes nearly identical to those of patients with UC (i.e., nearly 85% had functioning pouches 10 years after the operation). In this study, the diagnosis of CD in an IPAA, regardless of whether the patient previously had UC or indeterminate colitis was associated with poorer long-term outcomes. Other institutions also have shown that although pouch complications are higher in patients with indeterminate colitis, the functional results after IPAA for indeterminate colitis are identical to those after UC, unless CD develops, in which case results are not as good. In a large retrospective study by Delaney and colleagues in 2002, a diagnosis of indeterminate colitis was found to be associated with a higher risk of developing perianal fistula and pelvic abscesses, suggesting a clinical picture more consistent with CD; however, pouch failure rate was equivalent to those patients with UC.

Impact of Therapy with Biological Agents

The inclusion of newer biological therapies in the treatment of UC has raised concerns regarding their impact on the surgical outcomes after IPAA. In a study by Selvasekar and colleagues, 47 patients with UC received infliximab prior to restorative proctocolectomy and 254 did not. Patients who received infliximab were statistically more likely to have postoperative infectious complications and pelvic abscesses. In this study, after multivariate adjustment for disease severity and other medication use, infliximab remained independently associated with an increased risk of ileal pouch-related and infectious complications. Another study of 85 patients with UC who received infliximab preoperatively found that they were at increased risk for postoperative septic complications as well as late complications compared with patients who did not receive infliximab. The authors noted that patients who received infliximab were more likely to have undergone a 3-stage IPAA (total abdominal colectomy with end-ileostomy, followed by completion proctectomy and IPAA with loop ileostomy, followed by ileostomy closure), likely due to surgeon reluctance to perform an IPAA in the setting of preoperative infliximab administration. Both of these studies are limited in their ability to allow any conclusion regarding the exact role of infliximab in the increased postoperative infection rate, owing to the retrospective nature of the analyses and possible selection bias. Most likely, patients who require infliximab for treatment of their UC represent a sicker and thus higher-risk group of patients at the time of surgery. Further prospective studies need to be performed to clarify this important issue.

As previously discussed, pelvic sepsis and abscess are devastating postoperative complications and are the leading risk factor for ileal pouch loss. The use of vedolizumab did not increase the risk of postoperative complications compared with infliximab. In fact, the odds ratio for complications was lower in patients with UC. The number of complications in the pediatric population receiving biologics was the same as in those who did not receive a preoperative biologic agent, concluding that biologics may be safe to use in patients needing bowel resection.

Minimally Invasive Surgical Techniques

Laparoscopic Approach

The most important advance in surgical practice related to all of the procedures discussed earlier is the development of minimally invasive techniques. Minimally invasive colon and rectal surgery began in the early 1990s; however, improvements in image technology and instrumentation have only recently facilitated minimally invasive complex colorectal procedures. Laparoscopic approaches for IPAA were developed to reduce the impact of surgery on patients who are already physiologically stressed, to decrease length of hospital stay, to reduce morbidity, and to improve cosmesis. The initial reports of laparoscopic IPAA were discouraging, however, because of very long operative times and few observed postoperative benefits. Subsequent reports clearly have demonstrated the benefits of a minimally invasive approach in regard to postoperative decreases in length of stay, need for narcotics, overall morbidity, and return to normal function. Indications for operative intervention are not changed by the laparoscopic approach.

In a case-matched series from the Cleveland Clinic, 40 patients undergoing laparoscopic IPAA (LAP) were matched with open (laparotomy) controls for disease, age, gender, BMI, and date of operation. The LAP group exhibited significant benefits in times to ingesting clear liquids (1 vs. 3 days), eating a regular diet (3 vs. 4 days), and regaining bowel function (2 vs. 3 days). Duration of narcotic use was shorter in the LAP group, and length of stay was reduced (4 vs. 7 days). LAP patients had longer operative times (270 vs. 192 minutes), but operative time decreased with experience and now averages 180 to 210 minutes. Subsequent studies at the University of Texas Southwestern have continued to demonstrate these short-term patient benefits.

Benefits of the Robotic Approach

Robotic assisted laparoscopic surgery has been an emerging minimally invasive technique for colorectal surgery since it was first performed in 2001. This approach offers advantages over open and other minimally invasive techniques, including 3-dimensional visualization and 10-fold magnification, which may enhance identification and preservation of critical pelvic anatomical structures including autonomic nerves and perforating vessels. Moreover, robotic instrumentation effectively eliminates surgeon tremor and provides fine motion scaling. The robotic technology currently used most commonly in practice is the Da Vinci Robotic platform (Intuitive Surgical, Sunnyvale, CA). Pedraza et al. published a case series in 2011 in which the colectomy portion of the procedure was performed laparoscopically. The J pouch was fashioned extracorporeally via a Pfannenstiel incision, whereas the IPAA was performed intracorporeally using the robotic approach following a robotic proctectomy. The robotic approach achieved satisfactory outcomes with regard to operative times (330 ± 47.4 minutes) and length of stay (5.6 ± 2.6 days); this is comparable to reports from studies with the conventional laparoscopic approach. From 2006 to 2009, in 3 series comprising 179 patients who underwent total proctocolectomy and IPAA, the mean operative time was 298 minutes with a complication rate of about 30%. These data suggest that the robotic approach is safe and feasible for total proctocolectomy and IPAA in patients with UC (or FAP). Further studies are needed, however, to determine whether this approach provides an advantage for the goal of returning patients to normal function in the most cost-effective, expeditious manner.

Pathophysiologic Consequences of Proctocolectomy

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