Laparoscopic Total Abdominal Colectomy Research Articles

A Propensity Score-Matched Analysis of Single-Port vs. Multi-Port Laparoscopic Total Abdominal Colectomy with End Ileostomy for Medically Refractory Ulcerative Colitis.

Medically refractory ulcerative colitis (UC) necessitates surgical intervention, with total abdominal colectomy with end ileostomy being a definitive treatment. The comparison between single-port and multi-port laparoscopic surgery outcomes remains underexplored. To compare the surgical outcomes of single-port versus multi-port laparoscopic surgery in patients undergoing total abdominal colectomy with end ileostomy for medically refractory UC. A retrospective analysis comparing single-port to multi-port surgery in UC patients from 2010 to 2020. Patients were propensity score-matched 3:1 (multi-port to single-port) on baseline characteristics. Single center academic hospital. Binary outcomes were compared using a multivariable logistic regression model, and a subset analysis was conducted for postoperative stump leak based on stump implantation during surgery. These metrics were compared between the single-port and multi-port groups to assess the differences in surgical outcomes. The multi-port and single-port groups included 642 and 114 patients, respectively. Matched cohort included 342 multi-ports and 114 single-ports. We observed a statistically significant difference in mean operation time, with the single-port procedure taking 43 minutes less than the multi-port laparoscopy. There were no significant differences between the two groups in postoperative stump leaks, postoperative ileus, stoma site complications, postoperative readmission within 30 days, postoperative reoperation within 30 days, and subsequent IPAA surgery. In the subset analysis, stump implantation was associated with a higher risk of stump leak in the multiport group. The single-port group had a shorter hospital stay. Retrospective nature, being conducted at a single center. Single-incision laparoscopic total abdominal colectomy in the treatment of mucosal ulcerative colitis is a safe, effective, and efficient approach. In our cohort, as compared to multi-port approach, single incision laparoscopy has shown shorter operation times and better overall length of stay. Taking into account less invasive approach, decreased abdominal trauma, and faster recovery, single-port surgery is a viable alternative to multi-port surgery. See Video Abstract.

Preoperatively Confirmed Idiopathic Myointimal Hyperplasia of the Mesenteric Veins: A Case Report

Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare cause of colonic ischemia. First documented in the literature in 1991, this condition has remained exceedingly rare, with only a limited number of case reports since its initial mention. It involves proliferation of intimal smooth muscle within the mesenteric veins, resulting in colonic ischemia due to venous constriction and non-thrombotic occlusion. Patients experience a prolonged clinical course and adverse outcomes due to its rarity and nonspecific symptoms. The definitive diagnosis is typically confirmed after surgical resection of the affected colon, as initial biopsies are not deep enough to confirm the diagnosis. Histological examination of these biopsies reveals arteriolization of capillaries, subendothelial hyaline deposits, and fibrin thrombi. We present a case of a patient with a one-year history of diarrhea and abdominal pain. Biopsy samples obtained during colonoscopy showed colitis and proliferation of muscularized capillaries, consistent with IMHMV, prior to colon resection. The patient ultimately underwent laparoscopic total abdominal colectomy to the distal one-third of the rectum with end ileostomy. IMHMV is commonly treated surgically and mismanagement of this condition involving corticosteroids and immunomodulatory agents may result in unfavorable outcomes. This case report is one of the few cases of IMHMV diagnosed preoperatively within existing literature, which highlights a rare etiology of nonspecific colitis, emphasizing the critical divergence in its management approach.

Laparoscopic Total Abdominal Colectomy with End Ileostomy.

Laparoscopic Total Abdominal Colectomy with End Ileostomy.

Laparoscopic Total Abdominal Colectomy with Ileorectal Anastomosis for Crohn's Colitis and Multifocal Dysplasia

Watch full-length, narrated procedure of a laparoscopic total abdominal colectomy performed by Dr. Richard Hodin at MGH on a 59-year-old male with Crohn's disease and recent findings of multifocal dysplasia on colonoscopy.

Single-incision laparoscopic clockwise continuous total abdominal colectomy with end ileostomy in ulcerative colitis; surgical technique and results of a 7-year experience

Total abdominal colectomy with end ileostomy is the first stage of the three-stage surgical treatment of medically refractory ulcerative colitis. Laparoscopic surgery is a safe approach offering several benefits. Single-incision laparoscopic surgery is an alternative minimally invasive approach providing excellent cosmetic results. Literature on single-incision laparoscopic clockwise continuous total abdominal colectomy in the treatment of ulcerative colitis is limited. Aim of the study is to describe our surgical technique and report the outcomes. Medically refractory ulcerative colitis patients who underwent single-incision laparoscopic clockwise continuous total abdominal colectomy with end ileostomy by a single surgeon between January 2013 and December 2020 at our tertiary care center are included. Patient charts were reviewed retrospectively. 52 patients were included in the final analysis. 51.9% patients were male with the median age of 31.5years and body mass index of 22.2kg/m2. Median duration of operation was 100min with estimated blood loss of 50ml. There were no intraoperative complications, conversions to conventional laparoscopy or open surgery. Postoperative complications were reported in 13 (25%) patients with most common being ileus (17.3%). 3 patients had surgical site infections. 2 patients had postoperative bleeding requiring blood transfusion. 2 patients had reoperation within postoperative 30days. Median length of hospital stay was 2days. No mortalities were reported. Single-incision laparoscopic clockwise continuous approach is safe and effective in ulcerative colitis patients undergoing total abdominal colectomy with end ileostomy. Further prospective randomized studies are warranted.

Prospective randomized comparison of three-dimensional (3D) versus conventional laparoscopy in total colectomy for ulcerative colitis.

3D laparoscopy has been proposed with the aim of improving the depth perception and overall operative performance. To aim of this study is to compare 3D laparoscopy with conventional 2D laparoscopy in terms of operative time and visual parameters. This is a prospective, randomized, single-center trial designed to determine 10% reduction in the mean operative time. Ulcerative colitis patients >18 years of age who underwent laparoscopic total abdominal colectomy with end ileostomy between 2015 and 2020 were included. Patients were randomized into 3D and 2D laparoscopy groups. Duration of operation and surgeons' evaluation of the visualization system were the primary outcomes. Fifty-three subjects (26 in 2D, 27 in 3D group) were included in the analysis, with 56% being male. Mean age and body mass index were 40 (16.3) years and 23.5 (4.7) kg/m2 , respectively. Twenty-five subjects underwent single port laparoscopic surgery, of whom 13 were in 3D and 12 in 2D group. Mean operative time was 75.3 (30.8) versus 82.7 (38.6) minutes (P=0.4) for 3D and 2D groups, respectively. Operative times spent for individual steps were comparable. Post-operative minor complications (8 in 3D versus 8 in 2D, P=1) and median number of times for scope maintenance were also similar between the groups. 69% of the visual evaluation survey results favoured 3D over 2D (P=0.014). Three-dimensional laparoscopy for total colectomy in ulcerative colitis patients is safe and feasible option providing better visualization with no difference in operative time.

How to Do It: Laparoscopic Total Abdominal Colectomy with Complete Mesocolic Excision (CME) for Transverse Colon Cancer in Ulcerative Colitis

BackgroundUlcerative colitis (UC) is a chronic mucosal inflammatory bowel disease of the colon and rectum. After 10 years of having the disease, there is a significant risk of dysplasia or cancer in the affected colon and rectum, and because of the often aggressive biology of these tumors, frequent endoscopic surveillance is warranted. Over a third of patients with UC will ultimately require an operation, and although for specific cases alternative operations can be pursued, most patients prefer an ileal pouch-anal anastomosis (IPAA) with J-pouch construction. CaseA staged IPAA removes the affected colon and rectum treating UC and also restores intestinal continuity. However, the standard colectomy for UC includes low ligations of the main colonic vascular pedicle branches (ileocolic, right colic, middle colic and inferior mesenteric) that does not address a proper oncologic operation. A high ligation of the named vessels as well as a proper resection of the affected colon with its mesentery and lymph node package are needed to treat colon cancer. Analogous to a total mesorectal exicision for rectal cancer, a more radical procedure to remove the tumor and lymph node packet for colon cancer is described as a complete mesocolic exision (CME) in efforts to increase disease free survival. DiscussionWe demonstrate a laparoscopic subtotal colectomy for UC, with an oncologic complete mesocolic excision for a left transverse colon carcinoma in the setting of chronic mucosal inflammation secondary to chronic UC as the first procedure in a 3-staged IPAA. In the video, it is also demonstrated how the lymph node dissection is extended towards the greater gastric curvature and comprising omentum and gastrocolic ligament. There were no postoperative complications in the 44-year old male patient.

Single-Incision Laparoscopic Clockwise Continuous Total Abdominal Colectomy with End Ileostomy for Ulcerative Colitis

Single-Incision Laparoscopic Clockwise Continuous Total Abdominal Colectomy with End Ileostomy for Ulcerative Colitis

S2746 Mesenteric Venous and Portal Vein Thrombosis in a Patient With Ulcerative Colitis: Delayed Post-Operative Presentation or Hypercoagulable State?

Introduction: Mesenteric venous thrombosis (MVT) and portal vein thrombosis (PVT) are conditions involving occlusion of the vascular supply of the intestinal system. The symptoms of MVT and PVT may be nonspecific, however, patients may present with acute abdominal pain. The cause of venous thrombosis of the gastrointestinal system may be multifactorial, including patients with pro-coagulable conditions. Here we present the case of a patient with ulcerative colitis (UC) who underwent a recent colectomy with end ileostomy and arrived at the Emergency Department (ED) with acute abdominal pain secondary to superior mesenteric vein thrombosis extending into the portal vein. Case Description/Methods: This is the case of a 40-year-old male with a history of refractory ulcerative colitis diagnosed 7 years before admission, with evidence of disease on descending, sigmoid, and rectum. He underwent laparoscopic total abdominal colectomy with end ileostomy a month before admission. His symptoms were controlled with Ustekinumab and Prednisone tapering. The patient arrives at the ED with symptoms of tenesmus, generalized abdominal pain, and rectal bleeding. His physical examination was remarkable for hemodynamic stability and diffuse abdominal pain on palpation, without rebound or guarding. Abdominopelvic computed tomography with intravenous contrast revealed a large intramural thrombus extending from the superior mesenteric vein into the portal vein. The patient was started on an intravenous heparin drip, which was transitioned to direct oral anticoagulation therapy prior to discharge. Discussion: Patients with ulcerative colitis who require surgical intervention are at an increased risk of thromboembolic events. Here, we presented the case of a patient with evidence of extensive portomesenteric thrombosis with delayed onset after surgical intervention. Post-operative thrombosis is prevalent within 7-10 days after surgery. However, our patient presented with extensive thrombosis more than 1 month after the intervention. Our case raises concerns regarding the multifactorial etiology of the patient’s presentation. Moreover, UC has been known to increase prothrombotic state. Therefore, this case highlights how MVT in patients with UC may be secondary to a combination of factors, such as the hypercoagulable state of UC due to chronic inflammation and mechanical endothelial injury from surgical intervention. Prompt evaluation is essential to prevent intestinal infarction and reduce morbidity and mortality in these patients.

The Incisionless Totally Laparoscopic Total Abdominal Colectomy: How I Do It?

Laparoscopic total abdominal colectomy (TAC) is the optimal operative approach for patients with medically refractory inflammatory bowel disease and other benign colon conditions. Minimally invasive techniques for TAC are safe, appropriate, and associated with faster recovery than open surgery. This may be of particular importance in patients who ultimately undergo proctectomy with or without intestinal pouch reconstruction. We describe approaches to the laparoscopic TAC.

The reduced risk of septic shock/sepsis with laparoscopic surgery among ulcerative colitis patients with preoperative chronic steroid use

BackgroundPreoperative steroid use has been associated with worse surgical outcomes. The purpose of this study was to determine whether laparoscopic surgery reduces the risk of septic shock/sepsis among ulcerative colitis patients with preoperative chronic steroid use. MethodsPatients with ulcerative colitis undergoing a total abdominal colectomy were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2005–2019). Patients were stratified based on preoperative chronic steroid use and operative approach (open versus laparoscopic). The primary outcome was septic shock/sepsis. Multivariable regression models were used to assess the association between laparoscopic surgery and rates of septic shock/sepsis among steroid users and non-steroid users in both the elective and emergent settings. ResultsAmong 8,644 patients undergoing a total abdominal colectomy, 67.1% were steroid users and 32.9% were non-steroid users. Compared with an open approach, elective laparoscopic surgery was associated with lower rates of septic shock/sepsis, albeit with higher readmission rates for both steroid users (15.1% [laparoscopic] vs 12.0% [open], P = .005) and non-steroid users (12.6% [laparoscopic] vs 9.4% [open], P = .019). On adjusted analysis, ulcerative colitis patients with chronic steroid use undergoing an elective laparoscopic total abdominal colectomy demonstrated a reduced risk of septic shock/sepsis compared to open surgery (odds ratio 0.61, 95% confidence interval 0.49–0.76, P < .001). Similar findings were seen among chronic steroid users undergoing emergent laparoscopic procedures (odds ratio 0.54, 95% confidence interval 0.31–0.95, P = .031). ConclusionLaparoscopic surgery was associated with a reduced risk of septic shock/sepsis among ulcerative colitis patients with preoperative chronic steroid use, suggesting that minimally invasive surgery may be a promising option among this unique patient population.

Early Experience with Single-Incision Laparoscopic Total Abdominal Colectomy in Children.

Single-incision laparoscopic surgery for pediatric colorectal disease has been shown to be feasible and safe; however, the literature is scarce regarding the outcomes of single-incision laparoscopic total abdominal colectomy (SIL-TAC) in the pediatric population. The purpose of this pilot study was to review our initial experience and outcomes with SIL-TAC. A retrospective review of patients who underwent SIL-TAC from 2013 to 2015 was performed. General demographic and outcome data were analyzed. Five patients were included. Indications included ulcerative colitis (n = 4) and colonic dysmotility (n = 1). The median age was 13.5 years (8.5-19.4 years) and the median body mass index (BMI) percentile was 77.4 (2.2-98). The median operative time was 182 minutes (163-244 minutes). One case was converted to an open procedure. The median postoperative self-reported pain score was 2.8 (1.2-4.5). The median time until initiation of a diet was 2 days (1-8 days). The median length of hospital stay was 5 days (3-11 days). There were no 30-day complications. SIL-TAC is feasible and safe in children and offers improved cosmesis.

Familial Adenomatous Polyposis (FAP): A Rare Presentation of Severe Anemia with Pancytopenia

While anemia is present in nearly one quarter of patients at the time of primary diagnosis of FAP and varies in severity and incidence depending on anatomic site of carcinoma, the full range or degree of anemia and coexistent cytopenias are not well described. A 26-year-old Caucasian-American male without notable medical history presented with dyspnea, fatigue and night sweats for three days associated with a ten-pound weight loss over the past month. The patient was febrile, tachycardic, and pale on examination. Initial evaluation revealed pancytopenia with a significant iron deficient anemia (Hb 3.7 g/dL, MCV 52.4 fL, iron 12 ug/dL, ferritin 7 ng/mL, percent iron saturation 3.8), neutropenia (1100/uL WBC, ANC 675/uL), and thrombocytopenia (96,000/uL PLT). The patient was initially managed for neutropenic fever with suspicion of infection or hematological malignancy. Fecal occult blood returned positive. Infective evaluation was negative. CT demonstrated splenomegaly with non-enlarged scattered lymph nodes. Bone marrow biopsy revealed absent iron stores without evidence of malignancy. After resolution of neutropenia, colonoscopy revealed innumerable pedunculated and semi-pedunculated polyps from rectum to cecum. Pathology returned with multiple fragments of tubular adenomas, negative for high-grade dysplasia or malignancy. Genetic evaluation diagnosed FAP with a heterozygous mutation in the APC gene. Laparoscopic total abdominal colectomy with ileorectal anastamosis confirmed two synchronous invasive moderately differentiated colonic adenocarcinomas arising from separate tubular adenomas, polyposis coli, and metastatic disease involving 1 of 43 mesenteric lymph nodes, defining a stage IIIA pT2M1aM0 colon cancer. The patient now continues with his second cycle of modified FOLFOX chemotherapy. The case above fits the general description of presentation for FAP based on studies to date with fecal occult blood positivity (59% overall) and microscopic bleeding detected in 72% of patients between 20 and 40 years old. Nearly a quarter of patients suffer from anemia overall, ranging by age group (21% age 20-40, 17% age over 40) and location of carcinoma (35% rectal, 44% colonic, 43% small bowel). To the author's knowledge, there are no consistent reports regarding degree of anemia or other cytopenias, which evidently range from mild to severe, even without a history of visible colonic bleeding.

Giant Inflammatory Pseudopolyposis Mimicking Colonic Tumor in an Ulcerative Colitis Patient

Introduction: We report a case of giant inflammatory pseudopolyposis in an ulcerative colitis patient who had been refractory to medical management and eventually had a total colectomy. Case Report: A 21-year-old man presented with fatigue, unintentional weight loss, and intermittent abdominal pain. He developed significant anemia, and his hemoglobin levels were 7.1 g/dL. He was diagnosed as having pan-ulcerative colitis after a colonoscopy that demonstrated moderately severe colitis extending from the rectum to hepatic flexure. Additionally, colonic biopsies showed that he had chronic active colitis with cryptitis and crypt abscesses with glandular tissue distortion consistent with chronic inflammatory bowel disease. The patient was treated with budesonide-MMX and mesalamine, but his response was minimal, so his treatment was changed to anti-tumor necrosis factors - first adalizumab and then golizumab. A follow-up colonoscopy one year later showed a near-obstructing mass at the level of hepatic flexure and ascending colon, and it prohibited the movement of the colonoscope to the traverse colon (Figure 1). A computerized tomography scan of the abdomen demonstrated a solid appearing mass measuring 8 cm in size that was suspicious for a colonic neoplastic lesion (Figure 2). The patient then underwent a laparoscopic total abdominal colectomy and the resulting surgical pathology showed chronic, active ulcerative colitis with a diffuse infiltration of mixed inflammatory cells and large inflammatory pseudopolyposis but no evidence of dysplasia or malignancy. Discussion: Giant inflammatory pseudopolyps, defined as polyps larger than 1.5 cm in size, were first described in 1965 and tend to occur during the early and active disease course of young inflammatory bowel disease patients. The pathological features typically are a benign inflammatory process. Only one case has been reported with occult variable degrees of dysplasia. There are reported cases of regression of giant pseudopolyps after initiation of IBD therapy. When these pseudopolyps become refractory to medical treatment or cause obstructive symptoms, surgery is indicated.Figure 1Figure 2

Do the advantages of a minimally invasive approach remain in complex colorectal procedures? A nationwide comparison.

Since the introduction of laparoscopic colectomy, experience and technology continue to improve. Although accepted for many colorectal conditions, its use and outcomes in complex procedures are less understood. The purpose of this work was to compare the perioperative outcomes of laparoscopic transverse colectomy and total abdominal colectomy (study group) with an open approach (comparative group) and the more established laparoscopic right, left, and sigmoid colectomies (control group). This was a retrospective review of the Nationwide Inpatient Sample (2008-2011) of all patients undergoing elective right, left, sigmoid, total, or transverse colectomy as identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Risk-adjusted 30-day outcomes were assessed using regression modeling accounting for patient characteristics, comorbidities, and surgical procedures. The study included a national sample from a population database. There were 45,771 admissions: 2946 in the study group, 36,949 in the control group, and 5876 in the open comparative group. Mortality was the primary outcome. Secondary outcomes included in-hospital complications, length of stay, and hospital charges. The patients were predominantly white (73%), had private insurance (64%), and underwent surgery at urban centers (92%). Mortality was similar between the study and control groups (0.42% vs 0.51%; p = 0.52), with a higher complication rate in the study group (19% vs 14%; p < 0.01). The study group was also associated with a lower mortality rate compared with the open group (0.51% vs 2.20%; p < 0.01), which remained consistent after adjusting for covariates (OR, 0.38 [95% CI, 0.20-0.71]; p < 0.01). The study group had fewer complications overall compared with the open group (19% vs 27%; p < 0.01) and a shorter median length of stay (4.6 vs 6.3 days; p < 0.01). This was a retrospective study using an administrative database. A laparoscopic approach for total abdominal and transverse colectomies has similar mortality rates and slightly higher complications than the more established laparoscopic colectomy procedures and improved perioperative outcomes when compared with an open technique (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A178).

Total abdominal colectomy for severe ulcerative colitis: does the laparoscopic approach really have benefit?

It is still unknown to what extent the reported morbidity and recovery benefits of laparoscopic total abdominal colectomy (TAC) for severe ulcerative colitis (UC) are associated with patient selection bias. This study aimed to evaluate whether laparoscopic TAC has any advantages over open surgery after control for perioperative confounding factors. Patients undergoing TAC for UC during 2006-2010 were identified. Demographics, disease characteristics, and perioperative outcomes were compared between laparoscopic and open TAC. Postoperative recovery and 30-day complications were further assessed by covariate-adjusted multivariate regression models. The outcomes of different laparoscopic techniques were compared. A subgroup analysis including surgeons who routinely used both laparoscopic and open techniques was also performed. Of the 412 eligible patients, the 197 patients undergoing laparoscopic TAC were significantly younger and had a decreased Charlson Comorbidity Index and ASA score, increased hemoglobin and serum albumin levels, and a smaller proportion of extensive colitis and urgent cases. Unadjusted analyses showed that intraoperative morbidity, postoperative mortality, and rates for readmission and reoperation were similar. Laparoscopic TAC was associated with a longer operative time but a decrease in blood loss, overall morbidity, ileus, and thromboembolism, as well as a faster return to bowel function and a shorter hospital stay. After covariate adjustments, laparoscopic surgery remained associated with a reduction in the time to stoma function, incidence of postoperative ileus, and hospital stay compared with open TAC. The rates of postoperative morbidity, readmission, and reoperation did not differ regardless whether the conventional multitrocar technique, hand-assisted procedure, or single-incision technique was used. Laparoscopic TAC among surgeons using both open and laparoscopic techniques was associated with recovery benefits similar to those observed in the overall study population. The data suggest that laparoscopic TAC retains recovery advantages over open surgery even after adjustments for confounders.

Factors associated with postoperative morbidity, reoperation and readmission rates after laparoscopic total abdominal colectomy for ulcerative colitis

The aim of this study was to evaluate factors affecting postoperative outcomes after laparoscopic total abdominal colectomy (TAC) with end ileostomy (EI) for ulcerative colitis (UC). Patients undergoing laparoscopic TAC/EI for severe UC/indeterminate colitis in our institution between 1998 and 2010 were retrospectively identified from a prospectively established database. Demographics, disease characteristics and perioperative outcomes were recorded. Associations between the 30-day postoperative outcome and patient-, disease- and treatment-related variables were assessed using univariate and multivariate logistic regression models. Two hundred and four patients (105 men, median age 35.5 years) were identified. The conversion rate was 4.4%. Median blood loss and operation time were 100 ml and 185 min. Length of hospital stay was 5.8 ± 4.4 days. Overall postoperative morbidity, reoperation and readmission rates were 40, 7 and 17%, respectively Preoperative treatment with high steroid doses was significantly associated with postoperative morbidity on multivariate analysis (P = 0.011). Univariate analysis showed that lower preoperative body mass index (BMI), haemoglobin, serum albumin level and pancolitis were associated with reoperation, of which a lower BMI (P = 0.043) was also independently significant on multivariate analysis. No specific factor was significantly associated with readmission. Preoperative clinical deterioration is associated with an adverse outcome after laparoscopic TAC for UC.

Intraperitoneal or Subcutaneous

The optimal management of the closed defunctionalized large-bowel stump after laparoscopic total abdominal colectomy with end ileostomy for ulcerative colitis remains controversial. The aim of this study is to compare postoperative outcomes after different techniques of management of the defunctionalized (colo)rectal stump. Patients undergoing laparoscopic total abdominal colectomy for ulcerative colitis during 1998 to 2010 were assigned to an intraperitoneal group (creation of Hartmann rectal stump) or a subcutaneous group (subcutaneous placement of rectosigmoid stump). Postoperative morbidity was defined as complications occurred within 30 days after the operation or during the same hospital stay. Of 204 patients, 99 were in the intraperitoneal group and 105 were in the subcutaneous group. There were no significant differences in demographics or preoperative data, with the exception of a significantly increased age-adjusted Charlson Comorbidity Index and preoperative total parental nutrition use in the intraperitoneal group. There was 1 postoperative death for myocardial infarction in the subcutaneous group. Overall postoperative morbidity, pelvic sepsis rates, and length of hospital stay were similar. Stump leaks occurred in 5 patients in the intraperitoneal group vs 10 patients in the subcutaneous group (p = 0.23). All stump leaks in the subcutaneous group only required local wound treatments without causing pelvic sepsis or need for reoperation. Pelvic sepsis in the intraperitoneal group required reoperation in 1 case, CT-guided drainage in 3, and antibiotics alone in 2 cases. Pelvic sepsis in the subcutaneous group required CT-guided drainage in 3 cases and antibiotics alone in 1 case. With the limitations of a retrospective study, postoperative outcomes were comparable after either technique of stump management, none of which could offset the risk of pelvic sepsis. Subcutaneous placement of colorectal stump was associated with more frequent but less morbid complications.

Robotic‐assisted laparoscopic stage II restorative proctectomy for toxic ulcerative colitis

There is a paucity of literature reporting minimally invasive proctectomy for ulcerative colitis (UC). We report a novel application of a robotic system to perform restorative proctectomy in patients with toxic UC. Retrospective review, case series report. Robotic-assisted laparoscopic proctectomy with ileal J-pouch anal anastomosis was performed in three patients with toxic UC. All patients previously underwent urgent laparoscopic total abdominal colectomy. One female and two male patients were aged 39, 24 and 43, respectively. The procedures were performed safely with minimal complications. The robotic proctectomy operative time was reduced from 134 to 106 min. None of the patients have experienced fecal incontinence, nocturnal seepage or sexual dysfunction. This is a case series report of a robotic-assisted laparoscopic proctectomy with restorative ileal J-pouch in patients with toxic UC. This technique has been previously described for use in patients with medically refractory UC and neoplasia associated with chronic UC. This series exemplifies an ideal application of a robotic system with improved visibility, rotation and ergonomics.

Single-incision laparoscopic total abdominal colectomy for refractory ulcerative colitis

A three-stage restorative proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for the particularly debilitated patient with medically refractory ulcerative colitis (UC). Laparoscopic surgery has been shown to offer several advantages over the open approach in this setting. Single-incision laparoscopic surgery is an emerging minimally invasive strategy representing a truly scarless procedure for the first surgical step, namely, the total abdominal colectomy (TAC). Nine consecutive patients with medically refractory UC underwent a single-incision laparoscopic TAC between May and October 2010. All patients were on aggressive medical therapy with corticosteroids or immunosuppressors and were selected for this approach on the basis of their body habitus and the absence of relevant comorbidities. The whole operation was performed through a single access to the abdominal cavity, placed at the ostomy site marked preoperatively. Mean operating time was 142 ± 23 min, with an estimate blood loss of 108 ± 125 ml. No intraoperative complications or conversions to conventional laparoscopy or open surgery occurred. In all cases the postoperative course was uneventful. The return of bowel function was observed on postoperative day 1.7 ± 0.7, and patients could tolerate a solid diet on postoperative day 3 ± 0.5. The mean postoperative length of stay was 5.2 ± 1.3 days. In our experience, a single-incision laparoscopic approach to total abdominal colectomy for refractory ulcerative colitis has been shown to be safe and feasible. Initial results suggest that this technique can lead to improvements in short-term outcomes in selected patients.