30

How I do itTHE NATIONAL MEDICAL JOURNAL OF INDIA VOL.2, NO.!

The Technique of Restorative Proctocolectomywith Ileal Reservoir

W. G. EVERETT

INTRODUCTIONIn 1978 Parks and Nicholls! described the operation ofrestorative proctocolectomy with an ileal reservoir whichwas constructed from three loops of bowel having an'S'configuration. They found that with this type of reservoir,only fifty percent of patients could evacuate faeces spon-taneously; the others required a catheter. 2 This was not aproblem in patients with a two loop 'J' reservoir whichappeared to have an increased frequency of emptyingperhaps due to a smaller capacity. In an attempt to over-come this problem of evacuation Nicholls in 1984,3 andthe author independently at about the same time, deviseda four loop 'W' reservoir which is described here.

PREOPERATIVE PREPARATIONThe patient is admitted 36 hours before surgery. If a colec-tomy has not been performed previously the colon is pre-pared with a sachet of sodium picosulphate (picolax) 24hours before operation. During this time fluids only aregiven orally and the site for an ileostomy is marked. If acolectomy has already been done the rectum is washedout.

ANAESTHESIAA general anaesthetic is administered, an epidural catheterinserted and a caudal block performed with marcaine.Intravenous gentamycin 80 mg and metronidazole 500mg are started and continued tjll24 hours after the operation.

POSITIONThe patient is catheterized and placed in the modifiedlithotomy or Lloyd-Davis position. The abdomen andlegs are draped but the perineum is not prepared becausea rectal washout is performed at a later stage of the opera-tion.

PROCEDUREThere are 5 stages of the procedure:

J.Abdominal dissection and proctocolectomy2. Mucosal proctectomy3. Construction of the reservoir

W. G. EVERETI Addenbrooke's Hospital, Cambridge CB2 2QQ,England

4. Ileo-anal anastomosis5. Ileostomy and abdominal wound closure.

The abdominal dissection and proctocolectomyThe surgeon stands on the patient's left. One assistantstands opposite and another between the patient's legs.The abdomen is opened through a long midline incisionand a self-retaining retractor is inserted. The abdominalviscera especially the small bowel are inspected to ensurethat the patient does not have Crohn's disease.

The dissection begins by mobilization of the rectum.The sigmoid loop is lifted out of the abdomen and theremaining bowel packed out of the.way; this is aided by ahead down tilt of the table. The peritoneal reflection onthe left side of the sigmoid mesocolon is divided (Fig. 1).The left gonadal vessels and ureter are clearly seen and

.pushed backwards using a swab on a holder. Theperitoneum at the base of the right side of the mesocolonis then incised and a hole made in the mesentery just post-erior to the main vessels (Fig. 2). The index finger of theleft hand is placed through this hole to check that the leftureter lies behind the operator's hand. This position ismaintained while the inferior mesenteric vessels areligated and it is ensured that the ureter is not accidentallydamaged. The small bowel loops are packed out of theway and, with the help of a Kelly retractor, the posteriorabdominal wall below the duodenum is exposed. Theperitoneum is incised upwards to the right of the main

FIG 1. Division of the peritoneal reflection on the left side of themesosigmoid.

HOW I DO IT

FIG 2. After identifying the ureter (U) and gonadal vessels(GV) the mesocolon is incised posterior to the main vessels.

vessels and then transversely below the duodenum toreveal the inferior mesenteric vessels which are separatelyligated and divided (Fig. 3).

The surgeon then turns towards the foot end of thepatient to continue the dissection into the pelvis. Themesorectum is lifted upwards and carefully dissected offthe posterior abdominal wall. The hypogastric nerves liein the loose connective tissue and can be seen as two whitestrands in front of the lumbosacral disc, each passingdownwards towards the side wall of the pelvis (Fig. 4).Their preservation is important in the male as damagemay cause retrograde ejaculation.

Incision of the pelvic peritoneum is continued down-wards on either side of the rectum midway between the

,.

FIG 4. Identification of the hypogastric nerves at the pelvicbrim.

31

FIG 3. Ligation of the inferior mesenteric vessels.

bowel and the pelvic wall, joining the two incisions acrossthe front of the lower rectum. The rectum is thenmobilized posteriorly by dividing with scissors the looseconnective tissue between it and the sacrum and one ortwo small lateral vessels are diathermized. Blunt dissec-tion with a swab on a holder should be avoided as this maydamage pelvic nerves and small blood vessels. When therectum has been fully mobilized the lateral ligaments aredivided. These lie in the fat on either side of the rectum.Using a pair of long artery forceps the plane between thelateral rectal wall and the fat is found (Fig. 5). The fattypedicle is then clamped close to the rectum, ligated anddivided.

Once the rectum has been fully mobilized a Hays right

FIG 5. The pelvic dissection. The arrow indicates the plane to bedeveloped between the rectum and the fat which contains thelateral ligament.

32 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 2, NO.1

I

1IIIIII /:1I eo..III

16,

e", I- I, .

FIG 6. Preparing the small bowelmesentery. Ligation of right colicartery (RCA) and ileocolic artery(lCA). The arrow shows where themesentery is incised.

FIG 7. The terminal ileum is laidout as four loops with the cutdistal end on the patient'sright. X indicates the positionof the stay sutures. The dottedline is the line of incision.

angle clamp is applied. An assistant then washes theanorectum through a proctoscope, sucks out any residualfluid, and swabs the rectum with betadine. A sigmoido-scope is then inserted to measure the length of the anorectumwhichshould be no more than 7 to 8 em from the anal margin.A long rectal stump makes it difficult to remove themucosa and may obstruct the pouch being brought downto the anus. The rectum is divided with diathermy care-fully coagulating any large blood vessels.

The perineum is redraped and whilst the surgeon per-forms the mucosal proctectomy an assistant removes thecolon in the standard way with preservation of the omentum.The ileo-colic artery is tied flush with the main superiormesenteric trunk (Fig. 6). Added length of ileum can beobtained by incising the mesentery and mobilizing thesuperior mesenteric vessels where they cross the third partof the duodenum. If adequate length has been obtainedthe terminal ileum will come 5 or 6 em below the symphysispubis. A check of mobility can be carried out to assesswhether the bowel will come down to the anal canal.

Mucosal proctectomyA good headlight is essential for this part of the operationand it is advisable to have sandblasted instruments toavoid glare. A Parks retractor is inserted into the anus andthe submucosa above the dentate line infiltrated with1 : 300000 adrenaline solution. The mucosa is then dis-sected off the underlying muscularis propria from thedentate line upwards in 4 or 5 strips. Care is taken not todamage the muscle during dissection or by excessive useof diathermy.

FIG 8. The opened bowel edges aresutured from the mucosal surface. Ais joined to AI, B to B' and C to CI.

Construction of the reservoirThe terminal ileum is laid out as four loops with theobliquely cut distal end lying on the patient's right (Fig.7). Each of the four limbs, which measure 12, 12, 15 and12em from proximal to distal are held with Babcock forceps.Three stay sutures are inserted on the inner bend of eachbowel loop. These are used on completion of the reservoirto bring the inaccessible parts into view so the suture linecan be carefully inspected.

The bowel is then opened along its antemesenteric border(Fig. 8) and the cut edges approximated with an all-layercontinuous suture of 3/0 polyglyconate (Maxon'[ Davis &Geck). The stitching begins with the most distal of thethree posterior suture lines working proximally and dividingone loop of bowel at a time to id confusion andminimize bleeding. Once the back wall the reservoirhas been constructed suturing the front wa begins bymaking the outlet of the reservoir. This is done byapproximating the inferior edges of the bowel (Fig. 9) andthe distance between the two points should be such thatthe reservoir outlet admits two fingers (Fig. 10). Thisensures that it will be approximately the same size as theanal canal to which it will be sutured. Starting inferiorlythe anterior suture line is constructed using a mucosaburying stitch which is continued proximally to the inlet,which should have a wide oblique opening. The suturelines are then carefully inspected. It should not be possibleto admit a pair of forceps between stitches and wherethere are any gaps further sutures are placed. Where twosuture lines meet these are also reinforced by additionalstitches. The capacity of the reservoir is then measured

HOW I DO IT

FIG 9. The three completed posteriorsuture-lines. The anterior suture-line is started by joining D to D! tocreate the outlet of the reservoir.

FIG 10. The outlet should admit twofingers.

using a bladder syringe and its water tightness tested.Finally two lateral stay sutures are placed one on eitherside of the ou tlet of the reservoir. These are used to guideit down into the anal canal (Fig. 11). The cut end of theanterior suture is left long to aid in the orientation of thepouch.

The ilea-anal anastomosisA Parks retractor is used with foreshortened blades whichallow the reservoir to be brought down to the anal canalwithin the opened blades. A long artery forceps is passed

FIG 12. A Parks self-retaining retractor has been inserted intothe anal canal and the opening of the reservoir brought intoview. The anterior suture-line stitch has been left long and isuppermost.

33

A L

FIG 11. The completed reservoir.Two lateral stay sutures (L)are placed and the anteriorsuture-line stitch (A) is leftlong.

upwards through the anus to grasp each of the two staysutures in turn. With gentle traction the pouch is deliveredinto the anal canal. The cut end of the anterior suture liesuppermost and orientates the pouch (Fig. 12).

The ileo-anal anastomosis is constructed with inter-rupted stitches of 2/0 polyglactin (Vicryl'") mounted onan atraumatic 'J' needle (Ethicon) which can be easilymanipulated within the confined space of the anal canal.The first two stitches are placed anteriorly, one on eitherside of the anterior suture of the reservoir, and one stitchis placed posteriorly (Fig. 13). The Parks retractor is then

FIG 13. Two stitches have been placed anteriorly, one on eitherside of the anterior suture-line stitch, and one posteriorly.

34

I

\\\ ,

FIG 14. The retractor has been removed and its blades re-insertedwithin the reservoir. Two lateral sutures have been placed.

removed from the anal canal, and with gentle traction onthe lateral stay sutures the blades are re-inserted into thepouch. With the retractor placed laterally stitches areinserted at 90 and 270 degrees (Fig. 14). Each quadrant isthen sutured in turn with 3 or 4 stitches moving the retractorand angulating it as required to obtain good exposure(Fig. 15). With each stitch the needle first picks up the freeedge of the opening of the reservoir, then a small bite ofthe muscle half way up tlk anal canal and emerging at thecut edge of the mucosa. After the stitches are tied thesuture line is pulled upwards to come to lie in the mid-analcanal. Care should be taken not to take deep bites of theanal canal anteriorly where a fistula with the vagina mayresult in women. Before completing the two posteriorquadrants of the anastomosis a Redivac'" drain is passedupwards between the reservoir and anal canal on eachside and brought out through the abdominal wall.

Finally a Medina® catheter is placed in the reservoirand guided into position by ~he abdominal operator.

Ileostomy and abdominal wound closureA loop ileostomy is fashioned in the right iliac fossa. How-ever, this may be omitted if the ileo-anal anastomosis hasbeen performed satisfactorily and easily without tension,the patient is fit and not on high doses of steroids.

DISCUSSIONMost patients having restorative proctocolectomies areyoung and it is important not to cause sexual dysfunctionfrom damage to the pelvic nerves. The nervi erigentes areunlikely to be injured except where they sweep forwardsfrom the pelvic wall to the base of the bladder. The dissec-tion of the lower rectum should therefore be kept close tothe rectal muscles. In fact, impotence following restorativeproctocolectomy is surprisingly uncommon. The incidence

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 2, NO.1

FIG 15. Suturing of each quadrant.

of retrograde. ejaculation, caused by damage to thehypogastric nerves, however, is as high as 8% in someseries." This complication has been overcome completelyby Nicholls" who keeps the plane of dissection close to therectum. This is rather tedious and the author prefers to liftthe mesosigmoid off the posterior abdominal wall andidentify the hypogastric nerves which can be seen clearlyand preserved carefully. In 29 men whose sexual functionhas been assessed following surgery, none have had prob-lems with impotence or retrograde ejaculation.

The level of transection of the rectum appears to beunimportant from a functional point of view and divisionat the level of the anorectum gives as good results as leavinga longer cuff of rectum. 5 It is sometimes difficult to assessthe length of the rectum and it is advised that this ischecked with a sigmoidoscope before division. Thisavoids leaving too long a rectal stump which may causedifficulty in removing the proximal mucosa and a longmuscle cuff may prevent the reservoir from being broughteasily down to the anus.

The principal complication of the operation is pelvicsepsis" and every step should be taken to avoid this. Thepatient should be starved of solid food for 24 hours beforesurgery so there is no food residue in the small intestine tocause contamination of the peritoneal cavity. The rectalstump should be washed out before it is divided. Carefulhaemostasis is necessary throughout the operation butparticular care should be taken when dividing the rectumto coagulate the large vessels in its wall. A contaminatedhaematoma is a cause of pelvic sepsis but dehiscence ofthe ileo-anal anastomosis is the most important cause ofsevere pelvic sepsis. Accuracy in performing this ana-stomosis is fundamental to the success of the operation.This can only be achieved with precision by placing theblades of the Parks retractor within the reservoir whilesuturing.

HOW I DO IT

The type of reservoir constructed may not be as impor-tant as its capacity. Although Nicholls found that patientswith'S' and 'W' reservoirs evacuated less frequently thanthose with 'J' reservoirs the latter had a correspondinglysmaller volume'? An'S' reservoir has the great disadvan-tage that if the ileum is narrow it is not possible to insertthe blades of the Parks retractor into it and thereforeaccurate ileo-anal anastomosis is more difficult. Con-structing the reservoir with a single layer suture techniqueavoids diminishing its capacity and theoretically mayresult in greater compliance than a double layertechnique.

A major concern, besides continence, is the stretchingof the anal sphincter with the Parks retractor when per-forming the ileo-anal anastomosis. It is essential to havegood relaxation of the sphincters throughout the operation,and this can best be achieved by a combination of musclerelaxants, an epidural and a caudal block. With adequaterelaxation forceful stretching of the sphincter is avoidedand continence is not impaired.

This operation is a major advance in the managementof patients with ulcerative colitis in India and the thirdworld. In these countries drugs such as salazopyrine are

35

expensive, ileostomy bags are difficult to obtain and theiradhesive is of poor quality, and patients with ileostomiesfeel that they are social outcasts. By preserving the analsphincter and the normal passage for faeces these patientsmay be spared much discomfort and considerableexpense.

REFERENCESParks AG, Nicholls RJ. Proctocolectomy. without ileostomy forulcerative colitis. Br Med J 1978;2:85-8.

2 Parks AG, Nicholls RJ, Belliveau P. Proctocolectomy with ilealreservoir and anal anastomosis. Br J Surg 1980;67:533-8.

3 Nicholls RJ, Lubowski DZ. Restorative proctocolectomy: The fourloop (W) reservoir. Br J Surg 1987;74:564--6.

4 Dozois RR. Ileal 'J' pouch-anal anastomosis. Br J Surg 1985;72(suppl):S80-2

5 Dozois RR, Goldberg SM, Rothenberger DA, et al. Restorativeproctocolectomy with ileal reservoir. Int J Colorectal Dis 1986;1:2-19.

6 Nicholls RJ. Restorative proctocolectomy-The St Mark's experi-ence. In: Lee ECG (ed). Surgery of inflammatory bowel disease.Edinburgh: Churchill Livingstone, 1987:105-19.

7 Nicholls RJ, Pezim ME. Restorative proctocolectomy with ilealreservoir for ulcerative colitis and familial adenomatous polyposis:A comparison of three reservoir designs. Br J Surg 1985;72:470-4.