34. Laparoscopic-Assisted Proctocolectomy and Ileal Pouch-Anal Anastomosis

Abstract

Laparoscopic proctocolectomy with ileal pouch-anal anastomosis is indicated most commonly for ulcerative colitis and familial adenomatous polyposis. Antibiotics, steroids if indicated, and DVT prophylaxis are used preoperatively. The patient is carefully positioned after induction of general anesthesia. Four port sites, one of which is the planned ileostomy site, are selected. Proctocolectomy proceeds with sigmoid, descending, ascending, and transverse mobilization. This is followed by rectal dissection with transection at the level of the pelvic floor, then mesenteric transection, exteriorization, and resection at the terminal ileum with preservation of the ileocolic pedicle. A 15-cm pouch is fashioned, a stapled anastomosis is created at the top of the anal sphincter, and a proximal loop ileostomy is formed. Patients are advanced from clear liquids to solids by postoperative day (POD) 2, and are discharged between PODs 3 and 4. Potential complications include ureteral injury, ileus, bowel obstruction, high output ileostomy, and pouch leak. Patients can expect to have four to six bowel movements per day after closure of the loop ileostomy, and satisfaction is generally high.