Laparoscopic Total Colectomy and Ileoanal Pull-through Procedures

The laparoscopic total colectomy and ileoanal pull-through procedures are performed in patients who are diagnosed with ulcerative colitis or familial adenomatous polyposis (FAP).

These procedures involve removing the entire colon. The colon is then replaced with an internal pouch that your child’s surgeon will create. The pouch is then attached to the anus. Many patients prefer this procedure to other alternatives because they are able to go to the bathroom through their anus after the surgeries.

Your child could be a candidate if they have ulcerative colitis and:

• They are not responding well to medical management or are unable to be successfully weaned from chronic or long-term steroid therapy
• They have an urgent or emergency situation where an operation is necessary
• Their quality of life is being affected negatively, including:
  • The inability to consistently attend school
  • Side effects from the long-term use of medication
  • Failure to grow or develop normally
  • Missing out regular activities due to frequent "flare-ups"
• If your child has familial adenomatous polyposis (FAP)
• You want to decrease the risk of your child developing colorectal cancer when there is a family history of abnormal polyps in the colon.

Some examples of urgent or emergency situations that would require this procedure are:

• Infection
• Bowel perforation
• Severe bleeding
• Toxic megacolon (the most acute and least common)

Children with ulcerative colitis (UC) and FAP have several surgical options based on their unique needs. At Boston Children's, we offer the ileoanal reservoir (IAR) procedure with the creation of a J-pouch. This is also known as the ileoanal pull-through (IAP) procedure. We perform this procedure laparoscopically and/or robotically, which is a less-invasive approach.

Because UC and FAP affect only the lining of the large bowel, the IAR procedure can cure these diseases. We have found that there are fewer complications when we create a temporary ileostomy.

Surgery for creation of a 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 procedure or the two-stage procedure is best for your child. This recommendation will be based on your child’s specific condition and health. 

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 your child with someone of similar age and gender to talk through concerns and any questions you or your child may have, either by phone or in person.

In traditional "open" surgery, the surgeon uses a single incision to enter the abdomen. However, many children with UC may be candidates for a laparoscopic or robotic operation. A laparoscopic procedure is a minimally invasive surgery which uses several small incisions with the use of surgical instruments. Dissolvable stitches are used to close the incision sites.

We use these techniques to safely remove the entire colon and the lining of the rectum.

Stage 1: Bowel resection

• Laparoscopic/robotic procedure: The surgeon will make four small incisions in your child’s abdomen. They will then pass a scope into one of the incisions to observe the operation. They will place surgical instruments through the other three openings. 
• Colectomy: The surgeon removes entire colon (large bowel) but leaves the rectum in place.
• Ileostomy creation: The surgeon creates an opening at the end of the small intestine (bowel) and brings it through the skin of the abdominal wall to form a stoma, or ostomy. This is a temporary ostomy, which is needed until the J-pouch is created and has healed, which usually takes six to nine months. The stoma empties partially digested food into a pouch that is worn on the abdomen (belly).

Before your child leaves the hospital, we will show you how to take care of their stoma. We will also teach you information about skin care, pouch emptying, and how to put on a pouch before your child is discharged.

Most patients are discharged from the hospital within five to seven days post-procedure. The next stage of the operation usually occurs within a few months. This time frame may vary depending on the healing of the lining of your child’s rectum.

Stage 2: Pouch creation

The ileoanal J-pouch, or reservoir, is created from the lowest part of the small intestine (bowel). The surgeon will use about 6 to 12 centimeters of the ileum (last part of the small intestine) to create a J-shaped reservoir. They will separate the mucosa, or inner lining of the rectum, from the muscular wall. We will leave the muscle wall of the rectum 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 attaches it to the anus. Once the ostomy is closed, the stool can travel through the entire small bowel without leaking from the anus.

The surgeon will also bring a new temporary ileostomy out onto the abdominal surface where the previous one was. This allows the J-pouch and where it is sewn to the anus to heal properly. The procedure usually takes four to five hours, depending on your child’s condition. In about six weeks, after healing and regaining their strength, your child will be scheduled for an x-ray procedure to study the J-pouch.

We will place a catheter into your child’s anus to allow a small amount of contrast solution into the reservoir to make sure the areas have completely healed. We will teach you how to begin fluid "challenges" once a day.

Stage 3: 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 ("poop") can now flow directly into the internal pouch and be emptied out of the body through the anus.

The procedure usually takes about two hours to complete. We perform this operation through the same incisions as the previous surgery. Your child will stay in the hospital for three to five days and then have a follow-up visit a few weeks after surgery. They will have dissolvable sutures, and a clear plastic bandage will cover their incisions.

Once fully recovered, most people have between four to six bowel movements per day and can successfully pass gas without having an "accident."

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

The two-stage procedure combines the first and second stages of the three-stage procedure into one longer operation (about 7 to 8 hours). The second surgery is the "ostomy takedown," and it is the same surgery as the third stage of the three-stage procedure.

• Should I keep taking all my medications? Tell your anesthesiologist about all over-the-counter medications and prescription medication that your child takes regularly or occasionally. The team will discuss whether they need to reduce or stop taking any medication before the operation.
• How to prepare the bowel for surgery: Before the surgical procedure to remove the colon and create an ostomy, it is very important that your child’s bowel is cleaned out to minimize the risk of an infection. You will receive specific written instructions to help clean out and prepare their bowel before the operation. A nurse practitioner will contact you a few days before your surgery to answer any questions or concerns you may have. The day prior to surgery. your child will begin a clear liquid diet and continue that until they come to the hospital for surgery. We will likely give your child a few doses of antibiotics and “bowel cleanout” medication prior to surgery.

After your child’s surgery, they will need to recover at the hospital for about one week, but their stay is based on individual progress. Your child will also have a drain in their bladder and rectum that we will remove once pain medication has worn off. You will have a drain in place in your rectum for the first and second stages that is usually removed a day or two after surgery. 

You should expect to see yellow, slight pink, or clear mucus discharge via your child’s buttocks after the surgery. Patients are often discharged when they have good pain control and feel comfortable with management of stoma/good output via stoma. Our nursing team will assist you with how to manage your child’s stoma, empty the bag, and change the appliance. Most patients can return to activities four weeks after surgery.

Contact your child’s care team if they are experiencing: 

• Severe pain
• Vomiting green/yellow bile
• Decreased output via stoma/stoma change in color/appearance

Please call 617-355-7716 from 8 a.m. to 6 p.m. weekdays with these concerns. Please call 617-355-7800 if you’re calling at night/on weekends, and ask for the surgeon on call.

• Crohn's and Colitis Foundation of America (CFFA): 1-800-932-2423, ext. 212, or www.ccfa.org
• International Foundation for Functional GI Disorders (IFFGD): 414-964-1799 or www.aboutkidsgi.org
• National Digestive Diseases Information Clearing House (NIDDIC): 1-800-860-8747 or www.niddk.nih.gov
• United Ostomy Association of America (UOAA): 1-800-826-0826
• Wound, Ostomy & Continence Nurses Society: 1-888-224-9626 or www.wocn.org
• Youth Rally, a four-day camp for kids ages 11-17 who have had a bowel and/or bladder diversion: 856-854-3737 or www.rally4youth.org