Robot-Assisted Restorative Proctocolectomy and Ileal Pouch–Anal Anastomosis for Ulcerative Colitis

Abstract

Introduction:

Minimally invasive surgery is gaining more popularity in surgical procedure for ulcerative colitis (UC). ¹ However, the conventional laparoscopic approach is known to be associated with several limitations. ² Robotic surgery offers several advantages to overcome these limitations. ³ As laparoscopic total proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become an accepted procedure for the treatment of UC-associated colorectal cancer, less invasive surgery such as robot-assisted surgery has been introduced to improve surgical outcomes. ⁴ In this case report, we described the usefulness of a hybrid technique involving both laparoscopic surgery and robotic surgery in IPAA. Furthermore, this video demonstrates the anastomosis of an ileal pouch to the anal canal using a hand-sewn technique.

Case presentation:

A 43-year-old woman first noticed bloody diarrhea. She was diagnosed with left-sided type UC. In 2015, surveillance colonoscopy revealed an elevated lesion in the rectum. Endoscopic mucosal resection of the elevated tumor was performed and the histopathologic diagnosis from resected tumor revealed high-grade dysplasia. As pathologic findings of high-grade dysplasia are suggestive of the high probability of coexisting adenocarcinoma, we performed robot-assisted total proctocolectomy and IPAA for the patient.

Methods:

The patient was placed in a lithotomy position under general anesthesia. An open entry technique through the umbilical cicatrix was used to place the 12-mm camera port. After the inspection of the abdominal cavity, five other trocars (four 8 mm robotic trocar and one 12 mm trocar) were inserted. The robot (Da Vinci surgical system; Intuitive Surgical) was then docked from the left caudal side of the patient. The operation began with the mobilization of the sigmoid colon. After performing high ligation of the inferior mesenteric artery, inferior mesenteric vein was also divided. After the mobilization of splenic flexure, the dissection of the omental attachments to the distal half of the transverse colon was done. Then, the robot was temporarily undocked, and the mobilization of the cecum and ascending colon was performed laparoscopically. After the complete mobilization of the entire total colon, we extended the umbilical port site to 3.5 cm and total colon was extracted. The distal part of the ileocolic vessels, right colic vessels, and middle colic vessels was ligated and divided. Lone Star Retractor System™ (CooperSurgical, Trumbull, CT) was positioned to expose the dentate line, and the transanal dissection of rectal mucosa was performed. The robot was then docked, again, between the legs of the patient. The mesorectal excision was performed down to the levator ani. After complete mobilization of the rectum, the robot was undocked. Total colon, rectum, and ileum were extracted and 30 cm of terminal ileum was isolated to form J-pouch. Ileal J-pouch was created and taken down to the anus under laparoscopic guidance. The transanal anastomosis was performed by a hand-sewn technique. Covering ileostomy was created.

Results:

The total operating time was 411 minutes and the estimated intraoperative blood loss was 70 mL. The patient underwent ileostomy closure at 2 months after the primary operation, and there were no signs of recurrence at 11 months after surgery.

Conclusion/Discussion:

There were four reports that demonstrated the clinical outcomes of robot-assisted total proctocolectomy and IPAA. ^{5 –8} Previous reports showed equivalent operation time, blood loss, and postoperative morbidity rates of robotic IPAA compared with laparoscopic IPAA, and there was no case that was converted to laparoscopic or open surgery, suggesting that robotic IPAA is a safe and feasible procedure. In this case, the mean operative time and blood loss seem to be within acceptable limits. Furthermore, the patient has not experienced any postoperative complications. In conclusion, we reported a case of UC with dysplasia for which robot-assisted total proctocolectomy and IPAA are considered to be an effective procedure.

Authors' Contributions: All the authors substantially contributed to conception and design, acquisition of data, analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published.

Consent: Written informed consent was obtained from the patient for publication of this case report and accompanying images.

T.W. has received honoraria and research funding from Intuitive Surgical, Olympus, Covidien and Johnson & Johnson. For the remaining authors none was declared.

Runtime of video: 8 mins 24 secs

Presented at the 8th Annual Congress of the Japan Robot Surgery Society, in Tottori, Japan, on January 30, 2016 (in Japanese).