Laparoscopic TME with colonic J Pouch

Clinical Case:

• 76-year-old male
• No significant past medical history
• No prior surgeries
• Due to rectal bleeding, first colonoscopy in February 2019
• Bleeding, friable 4 cm diameter lest posterior lateral lesion, 6 cm from dentate line

Clinical History:

• 10mm polyp at 40cm proximal to anus, removed
• 25mm polyp nodular a sessile in the cecum, removed piecemeal with hot snare
• Multiple large mouth diverticula in the sigmoid and descending colon
• Rectal mass as described-biopsied
• Mass base of cecum-fragments of tubular adenoma
• Sigmoid 40cm polyp-hyperplastic
• Mass rectum - fragments of tubular adenoma with high grade dysplasia

Procedure Steps:

• Modified lithotomy position
• Three port technique in through umbilical, right lower quadrant, right upper quadrant ports
• Mobilize lateral to medial approach to mobilize left colon
• High ligation of inferior mesenteric artery, vein, and splenic flexure
• Total mesorectal excision
• Stapler transection
• Division of mesentery from high ligation to sigmoid descending junction
• Extracorporealization through an enlarged umbilical port incision through which a wound protector is placed
• Fluorescence angiography with resection of specimen and construction of colonic J-pouch
• Stapler introduction with anastomosis
• Placement of drain and creation of ileostomy

Learning Points:

• Only three ports needed
• Mobilize splenic flexure, IMA and IMV for length
• Create colonic J-pouch to optimizing function
• Utilize endoscopy to help assess anastomotic integrity
• Employ ICG to evaluate perfusion