Proctocolectomy with an ileoanal pouch is the procedure of choice for a variety of underlying diseases, such as ulcerative colitis (UC), classic familial adenomatous polyposis (FAP), and other polyposis syndromes or conditions with multiple synchronous cancers involving the rectum. Recently, the indications for Crohn’s colitis and slow-transit constipation are being revisited. Proctocolectomy with an ileoanal pouch is mostly indicated as an elective prophylactic procedure, rarely in the event of a manifest cancer.

Since the first description of the procedure in 1978 by Parks and Nicholls with an S‑pouch [1] and the J‑pouch by Utsunomiya in 1983 [2], the latter has become the overall recommended standard. Functional outcome has a major influence on quality of life (QoL; [3]) and the specifics of the underlying disease play an important role regarding, for example, an indication for protective ileostomy or completion of rectal resection as a total mesorectal excision (TME) or a “close shave” rectal resection.

In the event of an underlying FAP, desmoid tumors (aggressive fibromatosis) must be prevented, since they are not only the most predominant cause of mortality, but they also have the most decisive influence on QoL. Desmoids usually occur in the intestinal mesentery and growth is triggered or enhanced by trauma—a major argument against performing a routine ileostomy owing to double surgery at the identical ileostomy site. Leaving the mesorectum in place, instead of removing it in the corresponding sheath, may dispose the tissue to functional problems, such as desmoids, and cause malfunction of the pouch reservoir, such as therapy-refractory pouchitis, pouch in- or outlet problems, and fistulae.

Last but not least, the issue of the established, preferred double-staple anastomosis, which according to the literature yields better functional results than a hand-sewn anastomosis, must be challenged and the discussion on this subject resumed. For patients with UC, specifically “cuffitis,” and for patients with FAP, the sequelae of regrowth of neoplasia in the rectal remnant are a difficult clinical problem to resolve. This must be addressed and technically revisited, since both problems frequently necessitate a reoperation with resection of the rectal remnant and—against the aim—is often solved by fashioning a permanent ileostomy, with all the health and QoL constraints that this involves.

Diagnosis and surgical indication

The diagnosis and primary treatment of UC is conservative and lies in the hands of gastroenterologists. Surgery is an option for patients who are refractory to treatment and/or who present with dys- or neoplastic lesions. In children and adolescents, growth retardation may be another indication to proceed with surgery. Both indeterminate colitis and Crohn’s colitis without anorectal manifestation are no longer considered an absolute contraindication; however, it is mandatory to inform patients about the increased rate of pouch failure in these cases (approx. twofold compared with UC).

To determine the timing for prophylactic surgery in FAP patients, both the phenotype (clinical manifestation) and symptoms should be taken into account. Molecular genetic proof of the diagnosis of FAP and detection of a pathogenic mutation in the APC gene are preferable but not indispensable prior to surgery. The lack of proof of the underlying genetic cause does not influence the surgical indication. Symptoms that should drive toward prompt surgery include growth retardation, diarrhea, chronic anemia, or abdominal pain. A recently implemented international staging system, which classifies size, distribution, and histology of adenomas in FAP in conjunction with a recommended therapeutic strategy, is helpful and should be applied as preoperative score [4].

Choice of procedure

In classic FAP without cancer, as a basic principle one-stage laparoscopic (also secondary to previous abdominal surgery) proctocolectomy is pursued, whereas for the attenuated phenotype, laparoscopic (sub)total colectomy is the procedure of choice. The indisputable and clear advantage of the laparoscopic approach, including the beneficial effect on female fertility, is well-documented [5, 6].

As our general strategy, we aim to avoid both larger incisions and a routine protective ileostomy, to leave the omentum, and to perform a TME, if applicable as a transanal laparoscopic TME (taTME). If the laparoscopic approach is not feasible for technical reasons, our preference is a small Pfannenstiel incision and a hand-assisted completion of the colectomy. A deviation stoma is avoided in favor of a virtual ileostomy, as has been described by the authors [10], in conjunction with an anal tube, unless the tension of the pouch mesentery is worrisome or a primary anastomotic leak is demonstrated.

In the event of UC, indeterminate colitis, or Crohn’s disease, for reasons stated earlier, the primary laparoscopic approach for elective surgery is preferred, mostly as a two-stage procedure. In the emergency setting or in comorbid and immunosuppressed patients, an initial subtotal colectomy with preservation of a sufficiently long rectal remnant and terminal ileostomy, if possible laparoscopically with a single-port approach (at the site of the future ileostomy), is recommended. Consecutively, the single-port site is used for colonic specimen extraction and for fashioning of the terminal ileostomy. Laparoscopic completion proctectomy is pursued once the patient has recovered and medication can be reduced or omitted. Again, the single-port incision will be employed by closing the detached terminal ileum, repositioning into the abdomen for the abdominal preparation and rendezvous approach. The ileoanal pouch will later, by detaching the embryonic adhesions at the height of the sigmoid colon and moving proximally after long-segment visualization of the left ureter, be fashioned exteriorly after mobilization of the small bowel. A consecutive deviation will generally be avoided, especially since the mesentery is spontaneously elongated after a deviating ileostomy and therefore the pouch-anal anastomosis is generally tension-free.

Surgical procedure

The patient is placed in a Trendelenburg low lithotomy position and special care is taken to position the legs in well-padded boots (Fig. 1). The first incision is made in the umbilicus and after gas insufflation and an initial inspection of the abdomen, three to four trocars are placed under vision (positions are demonstrated in Fig. 2). A 5-mm trocar is positioned at the previously marked optimal site for an ileostomy. If a projected virtual ileostomy is performed, the vessel loops will be everted and secured at this trocar site.

Fig. 1
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Patient positioning: The patient is placed in a Trendelenburg low lithotomy position and special care is taken to position the legs in well-padded boots

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Fig. 2
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Postoperative illustration (day 5) with the virtual ileostomy in place

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The preparation is initiated by detaching the embryonic adhesions at the height of the sigmoid colon and moving proximally after long-segment visualization of the left ureter (Fig. 3). This is followed by exposure of the inferior mesenteric vessel pedicle and rather central transsection of both the vein and artery (approx. 2 cm distal to the origin) between clips. After close colonic dissection at the height of the splenic flexure, the greater omentum is preserved and the lesser sac is entered (Fig. 4). This preparation is continued along the transverse colon as far as easily feasible, usually until almost reaching the hepatic flexure (left-sided tilt of the patient for this procedural step).

Fig. 3
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Detaching the embryonic adhesions at the height of the sigmoid colon and moving proximally after long-segment visualization of the left ureter

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Fig. 4
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Opening of the lesser sac and detachment of the entire greater omentum from the left to the right flexure

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At this point, the surgeon and camera surgeon shift to the left side of the patient. We assume the preparation of the cecum and if necessary mobilize the appendix and the terminal ileum, lift and transsect the ileo-colic pedicle centrally. Dissection of the ascending colon beyond the hepatic flexure and completion of mobilization of the entire colon are performed next, also completing the mobilization and preservation of the omentum. Transsection of the colonic vessels ensues in clockwise direction. The right colic and the right and left branches of the mid-colic vessels are divided, again quite centrally. This is followed by dissection of the mesentery at the height of the ligament of Treitz and if required incision of the visceral peritoneum and mobilization of the mesenteric pedicle in order to gain optimal lengthening for the pouch (every millimeter counts!; Fig. 5). The entirely devascularized colon is positioned ventrally and the small bowel is folded in the upper left quadrant of the abdomen. The terminal ileum is divided with the linear cutter in close proximity to Bauhin’s valve.

Fig. 5
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Dissection of the mesenteric pedicle centrally and visualization of the mesenteric artery (arrow). The surrounding fatty tissue is dissected and if necessary the visceral peritoneum is incised for length gain

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The procedure is now continued with two simultaneous teams, if available. The abdominal team proceeds with the rectal dissection in the TME sheath, whereas a second team performs the taTME. For this, the patient’s legs are approximated to an intermediate height and the taTME monitor is positioned at the opposite cephalad side, for a comfortable monitor view. In order to insert the platform as atraumatically as possible and after placing the Lone Star retractor, intersphincteric injection of carbostesin is administered in four quadrants. If polyp growth reaches far down distally, as shown in this patient, after submucosal injection of 1:10 suprarenin a primary mucosectomy is preferred. The proximal purse-string suture—depending on the local appearance—may be fashioned under direct visualization or placed laparoscopically after insertion of the platform. This is followed by preparation of the extramesorectal sheath up to the rendezvous with the abdominal team. The surgeon decides, depending on general appearance and preference, whether the specimen is to be extracted transanally or via a small Pfannenstiel incision (the length of which depends on the size of the specimen). In this procedure, the transanal extraction is hassle-free (Fig. 6). Distal purse-string suturing is performed under direct visualization (Fig. 7) and the knot is placed on the advanced spike of the circular stapler for the anastomosis. Alternatively, at this point a 12-mm silicone drain may be advanced transanally and the purse-string suture tied upon it, as a guiding rod connected to the anvil in the pouch, in order to advance the pouch more easily into the pelvis. The ileoanal reservoir is constructed by exteriorization of the terminal ileum via the Pfannenstiel incision in a standardized fashion. As a distinctive feature, we emphasize deperitonealization of the pouch mesentery (Fig. 8) so as to gain additional length. If required and with the same aim, smaller arcades of vessels may be sacrificed utilizing diaphanoscopy to select them. In order to fashion the J‑pouch, we prefer the 60-mm-long linear cutter. The carefully selected apex of the pouch is slung with a vessel-loop and incised horizontally. We refrain from setting sustaining sutures. Importantly, the two limbs of the pouch must be manually separated and lateralized, and thus ideally both stapler lines are positioned accurately antimesenterically (Fig. 9). The first and the second firing of the cutter are illustrated and, importantly, with the second firing a blind loop on the short limb should be avoided. The unavoidable short blind loop of approx.1 cm is generously oversewn and as such abolished. The pouch limbs achieve a length of 10–12 cm. A hand-fashioned purse-string suture with Prolene serves to secure the anvil of the circular stapler (28/29 mm), and if so intended may be attached to the transabdominally advanced silicone drain, facilitating repositioning of the pouch intra-abdominally and advancing it into the pelvis. After connection of both stapler devices, we proceed with firing of the anastomosis under laparoscopic visualization. Caution must be taken not to pull any anal skin or sphincter muscle into the stapler when approximating the tissue. The impermeability of the anastomosis is tested via an air or dye test. This is followed by insertion and fixation of the transanal tube that is left in place for 5 days (Fig. 10). Abdominally, a drain is placed behind the pouch and exteriorized via the left-sided trocar. Next, usual closure of the abdominal incisions is performed and intracutaneous skin closure with a resorbable monofilic suture. A limited postoperative fluid intake is allowed. Nutrition uptake follows removal of the anal tube. As a general approach, bowel movement is regulated with loperamide.

Fig. 6
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Transanal retrieval of the entire proctocolectomy specimen

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Fig. 7
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Transanal fashioning of the distal purse-string suture

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Fig. 8
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Peritonectomy of the mesentery and incision of the visceral peritoneum with dissection of arcades for lengthening if required

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Fig. 9
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The ileoanal pouch is fashioned after the horizontal antimesenteric incision of the bowel wall by placing two consecutive stapler lines with a 60-mm linear cutter. a First and b second stapler line. Importantly, note the strict antimesenteric placement of the stapler line

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Fig. 10
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Insertion of the anal tube that is fixed with a suture

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Results

Since the introduction of taTME (in 2015) at our institution, we have operated on 12 patients following the approach described herein. We diagnosed one abscess posterior to the pouch in one patient on the ninth postoperative day, which was successfully drained with an interventional tube. One case of reduced vascularization of the short limb of the J‑pouch has already been described elsewhere [14]. In all cases, the virtual ileostomy was removed between days 3 and 9. In the early postoperative course, one patient had a singular nocturnal experience of incontinence after removal of the anal drain. Patients were dismissed between postoperative days 10 and 16 with complete oral intake, complete continence, and medication of a maximum of six tablets of loperamide per 24 h.

Discussion

The most controversial aspects of the surgical approach described here are:

  1. 1.

    The primary transsection of the ileocolic vessels

  2. 2.

    Abandoning of routine ileostomy and usage of an anal drain

  3. 3.

    The taTME approach for the rectal resection

1: In order to achieve tension-free length of the mesentery for construction of the pouch, complete mobilization of the terminal ileum and the mesenteric pedicle is mandatory The Heidelberg school of Prof. Herfarth insisted on preservation of both the ileocolic and the mesenteric vascular arcades, with the aim of maintaining a double-fold vascular supply. In principle, however, only one of the two is required and either may be sacrificed for achievement of greater lengthening. In the Anglo-American literature, the general recommendation is to routinely transsect the ileocolic pedicle [7].

2: The crucial argument for avoiding a routine ileostomy in FAP patients is the increased posttraumatic induction of desmoid growth observed at this site [8]. In addition, fashioning and taking down of an ileostomy are associated with substantial morbidity. By performing a virtual ileostomy, additional safety may be achieved in the event a secondary deviation is required, since the prepared loop of small bowel may easily be exteriorized without the requirement of a relaparotomy [9]. The combination with an anal tube contributes to the overall concept, although this lacks documented evidence. A benefit for the approach of an anal tube has been described for rectal surgery [11]. In the event of an ileoanal pouch, the postulated beneficial effect has yet to be prospectively validated.

3: taTME with a “bottom–up” approach in the hands of the experienced offers the advantage of a potentially improved preservation of continence and of urogenital function [12]. Neuromapping may offer additional safety for nerve preservation. The feasibility of an ileoanal pouch construction with taTME and ileal pouch–anal anastomosis (IPAA) for UC was first described in 2015 [13]. Our experience with our first series of FAP patients was recently published [14]. As a rendezvous procedure with excellent visualization of the TME sheath, this procedure must be prospectively documented and evaluated regarding outcome—specifically QoL—for benign indications.

According to Bartels et al. [15], most surgeons perform TME as part of proctocolectomy and only a few opt for close rectal dissection (CRD). Both methods have advantages and disadvantages. In a small prospective randomized study, no difference between the procedures was found after 12 months, neither in terms of functional results nor in QoL. However, the CRD group had a lower incidence of complications. The extent to which taTME contributes to fewer complications and thus shifts the argument in favor of TME must be critically evaluated. In our experience, transanal manipulation did not have any negative effects in the small group of patients. The advantage of the double purse-string suture is that it allows for exact height determination of the anastomosis and a better circulation of the bilateral circular anastomosis with more effective removal of the rectal margin Whether this leads to a lower rate of insufficiency, better function, and avoidance of cuffitis and rectal neoplasia must be evaluated prospectively.

Practical conclusion

Data from the literature and the short-term results of the surgical approach described here allow us to draw the careful conclusion that a protective ileostomy is not required as a general rule. A virtual ileostomy in combination with anal drainage may offer a similarly good protection without the morbidity of an ileostomy. taTME is clearly an option for benign disease. A differentiated evaluation of the postulated benefit for IPAA patients must be performed by analyzing UC and FAP patients separately. The results—in addition to functional outcome—must also take desmoids, pouchitis, pouch failure, cuffitis, and rectal neoplasia (FAP) as well as QoL into account.