VM53 - Redo Two Stage Turnbull-Cutait with Delayed Coloanal Anastomosis Using Indocyanine Green

Purpose/Background: The Turnbull-Cutait abdominoperineal pull through with delayed coloanal anastomosis (TCDCA) has been well described since 1961. In regards to low anterior resections (LAR) for rectal cancers, TCDCA when compared to conventional single stage anastomosis have reported similar if not lower incidences of pelvic sepsis and anastomotic leak. Often patients undergoing TCDCA are inherently at higher risk for pelvic complications as this is typically not pursued as an index operation, rather for redo surgery after single stage anastomoses have failed. We present a video abstract of a TCDCA utilizing indocyanine green (ICG) to assess anastomotic perfusion after previous anastomotic leak in a patient with recurrent pelvic sepsis who refused permanent stoma.

Methods/Interventions: We present a 66-year-old Caucasian male with a history of hypertension, hyperlipidemia and tobacco abuse who initially was referred for a newly diagnosed rectal cancer. The patient received total neoadjuvant chemoradiotherapy 8 months prior and had an incomplete response. He was taken to the OR for robotic laparoscopic LAR with coloanal anastomosis and diverting loop ileostomy. Post operatively he developed a chronic posterior sinus resulting in chronic pelvic sepsis. Attempts were made to salvage this using endoluminal wound vac therapy over 6 weeks without success. He subsequently underwent a robotic revision of his LAR with colonic J pouch construction and repeat hand sewn coloanal anastomosis 8 months after the index operation. Unfortunately, this also developed a chronic draining presacral sinus posteriorly that was clearly noted on endoscopic evaluation.  Our team recommended end colostomy which he refused. As a last resort option, a TCDCA was proposed and the patient agreed.

Results/Outcomes: Intraoperatively, laparoscopic abdominal access was gained and pneumoperitoneum was achieved. Due to adhesions from prior surgery a hand assist port was placed through a Pfannenstiel incision and adhesions were taken down from previous colonic conduit mobilizations off the retroperitoneum. The splenic flexure was remobilized. We completely mobilized down to the pelvis until the abscess cavity was encountered and noted to be communicating with the previous anastomotic disruption on digital exam. The anastomosis was taken down transanally excising a 5 mm cuff. We transected the colon proximally at a point of healthy viable colon. The omentum was divided from the transverse colon to allow for adequate length. We debrided the chronic pelvic abscess and copiously irrigated the area using dilute betadine. Next, we carried the neo conduit out through the transanal opening while maintaining the marginal artery. This perfusion was confirmed and noted to be excellent using 3 cc of ICG. The conduit was wrapped with a non-adherent gauze. We assessed the conduit daily while he remained inpatient. He was brought back to the OR post operative day 4 and we again inspected the conduit which was notably well perfused. We transected the colon using a bipolar energy device and performed a hand sewn coloanal end to end anastomosis with absorbable braided suture. Again 3 cc of ICG was used to examine the coloanal anastomosis transanally and noted to have excellent perfusion. The patient discharged home immediately post operatively. He was seen in clinic 2 weeks postoperatively and anastomosis was noted to be well healed and completely intact.

Conclusion/Discussion: TCDCA using ICG is a safe alternative to traditional single stage coloanal anastomosis in high-risk patients.