Pan proctocolectomy with ileal pouch anal anastomosis …

Pan proctocolectomy with ileal pouch anal anastomosis

This video was one of six Runner-up videos from the 2019 KS National Robotic Surgery Awards screened at the November meeting of the Robotic Surgeons Council of India.  It was entered by Dr. Asfar Ahmed and also produced by Drs. Venkatesh Munikrishnan Sudeepta Kumar Swain.

Abstract, with full title: Robot Assisted Panproctocolectomy For Familial Adenomatous Polyposis

Introduction: Pan proctocolectomy with ileal pouch anal anastomosis is the preferred approach for restoration of intestinal continuity in patients with Familial adenomatous polyposis. Minimally invasive surgery has become more widely adopted for Ileal pouch anal anastomosis. Laparoscopy has the same limitation during the proctectomy portion including dissection in the mid-to-lower rectum attributed to angles created by bony confines of the deep pelvis and lack of visibility when constructing the anastomosis. Robotic surgery provides improved 3-dimensional and high definition visualization of the pelvis and multiple degree of freedom which greatly enhance the performance during the proctectomy and construction of the anastomosis.

Case presentation: 23-year-old lady presented to our outpatient department with history of bleeding per rectum for one month. Her mother had similar symptoms and diagnosed to have Familial adenomatous polyposis and passed away at the age of 36 due to advanced colonic cancer. She underwent colonoscopy was suggestive of multiple colonic polyp from rectum to caecum. We performed robotic assisted total pan proctocolectomy and ileal pouch anal anastomosis for the patient.

Methods: Patient was placed in Lloyd Davis position under general anaesthesia. An open entry technique through 1 cm right of the umbilicus was used to place 8mm camera port. After inspection of the abdominal cavity ,other trocars placed and robot was docket from left caudal side of the patient. Dissection started with mobilization of the rectum. Ligation of inferior mesenteric artery and vein performed. Rectum mobilized up to pelvic floor after safeguarding ureter and gonadal vessels. Distally rectum divided with Endoscopic stapler 45mm x 2. Then proceeded with left colon and splenic flexure mobilization. Middle colic ligated and transverse colon mobilized up to mid transverse colon. Robot redocked for right colon. Ileocolic vessel, right colic and right branch of middle colic vessel clipped and divided after safeguarding right ureter and gonadal vessel. After complete mobilization of colon and rectum, ileum divided with endoscopic stapler 45mm.Right iliac stomal incision made. Total specimen extracted through the stomal incision.30cm of terminal ileum was isolated to form J pouch. Ileal J pouch anastomosed with CDH stapler 29mm to anal canal. Covering ileostomy created.

Results: Total operating time was 190 minutes and the estimated intraoperative blood loss was around 70ml. There was no intraoperative complication. Patient was started orals on same day. Patient was discharged on Day 3.

Conclusion: Robotic approach during proctectomy and ileal pouch anal anastomosis offers significant advantages to a laparoscopic approach, extending our armamentarium of minimally invasive surgical technique to Ileal pouch anal anastomosis.

Robotic surgery video, with photos and narration, 06:35