VM03 - Totally Robotic Completion Proctectomy with Intracorporeal Ileal Pouch Anal Anastomosis

Purpose/Background: Recent advances in minimally invasive surgical (MIS) techniques have allowed surgeons to offer an MIS approach to patients who previously would have required open surgery. Herein, we present a patient who underwent successful completion proctectomy with ileal pouch anal anastomosis (IPAA) following a prior emergent open total abdominal colectomy using a fully robotic intracorporeal technique.

Methods/Interventions: The patient is a 51-year-old female with ulcerative colitis who presented in July 2022 with toxic colitis and free air. She underwent an emergent total abdominal colectomy with end ileostomy. After a delay of approximately one year to allow for preoperative weight loss (BMI 34), she presented for a completion proctectomy with IPAA. This video was recorded and edited by the named surgeons who work and train in the same high volume tertiary referral center.

Results/Outcomes: Initial diagnostic laparoscopy revealed only a few intraabdominal adhesions that were taken down laparoscopically. The right lower quadrant ileostomy was taken down and the site used as a 12-mm stapler port. Three additional 8mm robotic trocars were then placed across the abdomen, and a 5mm assist port was placed in the right flank. The remaining distal sigmoid and rectum were then mobilized in a medial-to-lateral fashion, and the proctectomy was performed within the anatomic avascular plane. The rectum was divided just above the pelvic floor with two fires of a robotic 60 mm blue load stapler.
The ileum was brought down to the pelvis in a natural J-configuration and the length from divided ileum to pouch apex was measured at 18 cm. Two ileal enterotomies were made at the top of the common channel, and then channel was then created with 3 sequential fires of a 60 mm white load stapler from proximal to distal. The distal channel was completed with a final staple fire from the bottom of the J-pouch. The common enterotomy was closed with running 3-0 barbed suture in two layers.
A 25 mm EEA anvil was passed through the stapler port and secured to the J pouch with a 3-0 barbed pursestring suture, which was then reinforced with an endoloop. An end-to-end stapled ileoanal anastomosis was then performed. Donuts were intact and a flexible pouchoscopy confirmed a patent anastomosis with a negative leak test and good hemostasis. A diverting loop ileostomy was created.
Operative time was 413 minutes and EBL was 10 mL. The patient did well postoperatively and was discharged home on postoperative day 5.
Limitations: This is a single procedure performed at a high-volume tertiary referral center. Despite the patient’s elevated BMI, her pelvic anatomy was quite favorable and the outcome of this procedure may not be generalizable to all patients.

Conclusion/Discussion: Robotic completion proctectomy with intracorporeal ileal pouch anal anastomosis is safe and feasible. This technique can offer an MIS approach to patients who otherwise would require open surgery, which may ultimately improve patient outcomes.