Abstract
Transanal total mesorectal excision is a viable minimally invasive approach initially developed for rectal cancer and now applied to benign disease as well. This chapter describes the application of this technique in performing a total proctocolectomy with ileal pouch-anal anastomosis (IPAA) through a transanal approach (TaIPAA). The abdominal colectomy may be performed laparoscopically with the J-pouch fashioned through the future ileostomy incision. Proctectomy is then performed transanally, and the pouch passed down for a stapled or hand-sewn anastomosis. The technique may be modified in the setting of a staged IPAA.
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Small bowel is eviscerated through the future ileostomy site. Pouch length can be assessed by measuring reach of the pouch apex to the symphysis pubis. Selective mesenteric vessel ligation can be performed to improve pouch reach (MP4 88076 kb)
Purse-string suture placed to approximately 2–3 cm proximal to the dentate line or just beyond the GelPOINT® path access channel. Care should be taken in anterior sutures to avoid deep bites into vagina or prostatic urethra (MP4 56249 kb)
Rectum is insufflated and full-thickness proctotomy created two thirds of the distance between the purse-string suture and transanal access channel (MP4 78324 kb)
Posterior entry into the total mesorectal plane requires steep dissection posteriorly (MP4 72522 kb)
If desired, intramesorectal dissection can be performed close to the rectal wall in benign disease (MP4 71986 kb)
Anterior dissection in a male should be performed close to the rectal wall preserving Denonvilliers’ fascia (MP4 75460 kb)
In women, the anterior dissection can be facilitated by digitizing the vagina to identify the correct dissection plane (MP4 64207 kb)
Dissection laterally is performed to connect the anterior and posterior dissection planes. This should be performed close to the mesorectum to avoid injury to the nervi erigentes (MP4 67938 kb)
Rendezvous is generally performed anteriorly. The abdominal team can assist with dissection here or help the transanal team by retracting the rectum upward or placing a retractor into the opening to help the transanal dissection (MP4 64174 kb)
The pouch is placed at the pelvic brim by the abdominal team who also helps assure proper orientation of the pouch as the transanal team grasps the pouch and pulls it down for anastomosis (MP4 73245 kb)
Selective mucosectomy can be performed depending on the clinical scenario and pouch reach (MP4 72409 kb)
The pouch can be hand-sewn directly to the rectal cuff or dentate line depending on the level of anastomosis (MP4 43648 kb)
Double purse-string stapled anastomosis can be performed. The abdominal team secures the anvil inside the pouch with 2-0 Prolene purse-string suture and ties a drain to the anvil to allow the pouch to be grasped and pulled down into the pelvis. The transanal team places a 0 Prolene purse-string suture to close the rectal cuff. After the anvil is pulled down and two ends of the EEA stapler are mated, the distal purse-string is tied and the stapler closed and fired (MP4 45985 kb)
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Zaghiyan, K., Gough, A., Fleshner, P. (2019). Transanal Total Mesorectal Excision for Inflammatory Bowel Disease: Cecil Approach. In: Bardakcioglu, O. (eds) Advanced Techniques in Minimally Invasive and Robotic Colorectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-15273-4_18
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DOI: https://doi.org/10.1007/978-3-030-15273-4_18
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