VM93 - Laparoscopic abdominoperineal excision of ileal J-pouch with pouch-anal anastomosis and end ileostomy

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Purpose/Background: Total colectomy with ileal pouch-anal anastomosis (IPAA) is a well-established surgical treatment for patients with Familial Adenomatous Polyposis (FAP) and Ulcerative Colitis (UC). However, this procedure can be associated with complications, most commonly pouchitis which can adversely affect the patient’s quality of life.

Methods/Interventions: With informed consent, video recordings were made using a laparoscopic camera and iPhone. Patient records were reviewed for history, operative report, and recovery.

Results/Outcomes: A 61-year-old female with UC underwent total proctocolectomy with IPAA and diverting loop ileostomy, followed by ileostomy closure. She developed recurrent pouchitis and diarrhea unresponsive to medications. The patient was positioned in modified lithotomy, bilateral ureteric catheters placed, and rectal irrigation performed. Left upper quadrant, lower quadrant and paraumbilical 10mm Hasson trocars were placed. After significant lysis of adhesions from the abdominal wall, 3 additional 10mm ports were placed through an infraumbilical, right upper and lower quadrant incisions. The small bowel was mobilized from the duodenojejunal flexure to the top of the J-pouch. Both ureters were carefully identified and reflected out of harm's way. The presacral space was entered and the entire pouch was mobilized. The pelvis was narrow and due to the abscess, there was intense dense fibrosis. After full pouch mobilization, the mesentery at the afferent limb was divided with a 10mm LigaSure Atlas™. The afferent loop entry into the pouch was divided with a 60mm endoscopic linear cutting stapler. Next, the perineum was effaced with a Lone Star® retractor and an intersphincteric proctectomy was performed with electrocautery. The pouch was densely adherent to the posterior vagina within the abscess cavity with staples abutting the vagina. The pouch was excised and a vaginotomy was repaired with a 2-0 Vicryl™ suture. The abdomen was re-insufflated, and the expected seromyotomies and the 1 small antimesenteric enterotomy were repaired. After maintaining appropriate orientation of the ileum, it was delivered through the stoma site. The fascia and skin were decreased in circumference to allow a well everted stoma. A 19 mm Blake® drain was placed in the presacral space, and a Brooke ileostomy was created. The perineal wound was closed in layers and then covered with a dry dressing. At 2-month follow-up, she was well with a functioning ileostomy. She had persistent vaginal discharge, that is likely an old vaginal hematoma.

Conclusion/Discussion: Laparoscopic abdominoperineal excision of ileal pouch with pouch-anal anastomosis is our preferred option when patients request pouch excision.