V39 - Minimally Invasive Approaches to Small Bowel Mesenteric Lengthening for Tension Free Ileal Pouch Anal Anastomosis

CME Eligible

Purpose/Background: A 54-year-old male with history of ulcerative colitis who had underwent a laparoscopic total abdominal colectomy with end ileostomy presented to the colorectal surgery clinic to discuss creation of ileal pouch-anal anastomosis. On physical exam, his BMI was 31. After discussion with the patient, the decision was made to proceed with a robotic completion proctectomy with ileal-anal pouch anastomosis and diverting loop ileostomy.

Methods/Interventions: In this patient, once the end ileostomy was taken down and small bowel reach was measured, it was noted to be inadequate for a tension free reach for an ileal pouch anal anastomosis. The following procedures were deployed minimally invasively to allow for tension free reach of the small bowel to the pelvis. 1. The root of the small bowel mesentery was mobilized above the third portion of the duodenum and pancreas. 2. The mesenteric fat was stripped off the terminal ileum as there was significant scarring on the surface, and the mesentery was scored at other sites. 3. Terminal ileal vascular branches coming off the SMA arcade were isolated, and bulldog clamps were placed on two small arteries and two small veins coming off the arcade. The bowel was not ischemic after 10 minutes. Robust blood supply was also checked with ICG. The vessels were taken with vessel sealers and clips which led to adequate length for the pouch. Of note, the patient's ileocolic vessel had already been taken at the time of total colectomy. The small bowel reach extended by about 10cm with all these maneuvers.

The robot was undocked, the abdomen was desufflated, and the terminal ileum was extracted from the stoma site for creation of the ileal pouch. A total of 4 firings of the 60mm Echelon white load stapler were used to create an 18cm ileal pouch. A purse-string suture was secured around the enterotomy and a 25mm anvil from EEA stapler was placed. The robot was redocked for the completion proctectomy and the rectum was mobilized in a medial to lateral fashion and the IMA was ligated with the vessel sealer. The TME plane was dissected down to the pelvic floor, and the rectum was divided. ICG was used to assess perfusion, and the ileal-pouch anal anastomosis was created with the EEA stapler. The robot was undocked, the specimen was extracted, a drain was placed, the abdomen was closed, and a diverting loop ileostomy was created.

Results/Outcomes: The patient did well and was discharged on post-operative day 7 in a stable condition.

Conclusion/Discussion: Although lengthening maneuvers for adequate ileal-anal pouch anastomosis reach are often performed using open surgery, the robotic platform can be utilized and offers several advantages, including superior three-dimensional visualization, enhanced surgical precision, minimized tissue trauma, and smaller incisions