Laparoscopic total colectomy and illeoanal pullthough

These procedures involve removing the entire colon. The colon is replaced with an internal pouch that your child’s surgeon creates. This pouch is then attached to your child’s anus. Many people prefer this procedure to other alternatives because after all the surgeries, your child can go to the bathroom the "normal way".

A surgeon will create a temporary ostomy, which is a surgically created opening that begins in the intestine and goes through the skin of the abdominal wall. This opening is also called a stoma. When your child has an ostomy created, his stool will come out of his stoma into a bag or pouch that he wears. This is only temporary until your child’s body has healed from surgery. Once he has healed, he will be able to go to the bathroom the "normal way".

People with Ulcerative Colitis and Familial Adenomatous Polyposis have several surgical options. The surgical procedure offered at Children's is the Ileoanal Reservoir (IAR) procedure with the creation of a J-pouch. It is also known as the Ileoanal Pull Through (IAP) procedure. We also perform this procedure laparoscopically, which is a less invasive method.

Surgery for creation of an internal J-pouch or reservoir can be performed in either two or three operations referred to as "stages." Your child’s medical care team will decide if the three-stage or two-stage procedure is best for your child. Your child’s surgeon and your Gastroenterology (GI) doctor will discuss this with you.

You and your family may find it helpful to discuss the operation with someone else who has already had the procedure. Your surgeon or outpatient nurse will make every effort to match you up with someone of similar age and gender to speak with either by phone or in person.

Our expertise:

Children's approach to total colectomy is unique when compared to many other pediatric hospitals.

In traditional "open" surgery, the surgeon uses a single incision to enter into the abdomen. In laparoscopic surgery, the surgeon uses several small (3-5 millimeter) incisions through which surgical instruments are inserted and withdrawn. Each incision site is called a "port incision." At each port incision, a tubular instrument, called a trocar, is inserted into the abdomen. Specialized small instruments and a special tiny camera, called a laparoscope, are passed through the trocars during the operation.

At the beginning of the procedure, the abdomen is inflated (filled) with filtered air to provide a space for the surgeon to work. This space also helps the surgeon view the abdominal organs more easily. The laparoscope sends images from the abdominal cavity to high-resolution video monitors in the operating room. During the operation, the surgeon watches detailed images of the abdomen on the monitor. This system allows the surgeon to perform the same operation as traditional "open" surgery, but with smaller incisions.

We use these laparoscopic techniques to safely remove the entire colon and the lining of the rectum. This operation is performed using a combination of the incisions described above and a small version of the incision that babies are delivered through during C-section deliveries. Dissolvable stitches are used to close the incision sites.

• Laparoscopic surgery is sometimes referred to as "minimally invasive surgery."
• Your child’s condition will determine whether an open or laparoscopic surgical procedure is recommended.
• Patients who have a laparoscopic procedure may recover more quickly and return to normal activity in a shorter period of time.
• Some benefits of laparoscopic surgery include:
  • less post-operative pain
  • decreased length of hospital stay
  • smaller incisions
  • lower risk of cardiopulmonary complications
  • reduced risk of small-bowel obstruction.
• Patients who have had previous abdominal surgery may still be candidates for laparoscopic surgery.
• Scars after laparoscopic surgery are significantly smaller than the scar left after a traditional "open" operation.

Three-stage procedure:

This procedure is generally done when a patient is on high dose corticosteroids, or the disease is unresponsive to medical management. Severe inflammation or ulceration of the rectum makes successful removal of the rectal lining more difficult.

• First stage- bowel resection:
  • Colectomy removes the entire colon (large bowel) but the rectum is left in place.
  • Ileostomy creation:  A surgically created opening at the end of the small intestine is brought through the skin of the abdominal wall to form a stoma or ostomy.
  • The nursing staff will arrange for a visiting nurse to come to your home to review teaching. Your supplies will be ordered for you from a home care supply company.
  • Most patients are discharged from the hospital within five to seven days. After healing, regaining strength and getting weaned off medications, the next stage operation will be scheduled usually within a few months. This time frame may vary depending on the healing of the lining of your rectum and reconditioning.
  • This operation may be done as a laparoscopic procedure or with an open surgical incision depending upon the condition of both your child and his colon. Both procedures require general anesthesia in the operating room. The procedure usually takes four to six hours, depending on your child’s condition.
  • Laparoscopic procedure: Four small incisions will be made on the abdomen. A telescope is passed into one of the incisions to observe the operation. Instruments are placed through the other three openings. At the end of the procedure, the openings are closed and covered with clear plastic bandage over gauze.
     
• Second stage- the pouch creation
  • The illeoanal J-pouch or reservoir is created from the lowest part of your child’s small intestine. About 6 to 12 cm of the ileum (last part of the small intestine) will be used to create a J-shaped reservoir. The mucosa, or inner lining of the rectum, is separated from the muscular wall. The muscle wall of the rectum is left in place along with special sphincter muscles, which hold the stool inside the rectum or pouch. This part of the operation is done through the anus.
  • The surgeon then brings down the pouch and it is sewn to the anus. Once the ostomy is closed, the stool is able to travel through the entire small bowel without leaking from the anus.
  • A new temporary ileostomy is brought out onto the abdominal surface where the face one was. This allows the J-pouch and where it is sewn to the anus to heal properly.
  • In about six weeks, your child will be scheduled for an x-ray procedure to study the J-pouch.
  • A catheter is placed into the anus to instill a small amount of contrast solution into the reservoir to make certain the areas have completely healed.
  • You will then be taught how to begin fluid "challenges" once a day.
     
• Third stage- the ostomy takedown
  • Ileostomy is closed:This is called the "takedown" because the end of the ileum, which made the ileostomy stoma, is taken down from the abdomen wall and connected to the ileoanal reservoir. The old stoma site on the abdomen is now sutured closed. The intestinal output can now flow directly into the internal pouch and be emptied out of the body through the anus.
  • The procedure usually takes four to five hours, depending on your child’s condition. The operation is done through the same incisions as the previous surgery.
  • The ostomy site is closed with black sutures and then covered with gauze and tape. These sutures will be removed at your child’s first follow-up visit (10-15 days after the surgery). It does not hurt to have the sutures removed.
  • It is not uncommon to have eight to 12 watery-like stools per day in the first few weeks after surgery. It is important for your child to drink plenty of fluids to prevent dehydration. The natural enlargement of the reservoir, increased water absorption and greater muscle control may take between six to 12 months to reach its potential.
  • Your child may have occasional "accidents" during this early time of adjustment. This is most common during the night. Once fully recovered, most people have between four to six bowel movements per day and can successfully pass gas without having an "accident." Some people may need to get up during the night, but most do not.

Two-stage procedure:

The procedure can be done in two operations if your child has been on low dose corticosteroids, been responsive to medical management and his rectal lining is intact with minimal inflammation. The two-stage procedure is also done for people with FAP.

The two-stage procedure combines the first and second stages of the three stage procedure into one longer operation (about seven or eight hours). The second surgery is the "ostomy takedown" and it’s the same surgery as the third stage of the three stage procedure.