JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 00, Number 00, 2016 Full Report

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2016.0364

Vascular High Ligation and Embryological Dissection

in Laparoscopic Restorative Proctocolectomy
for Ulcerative Colitis

Deniz Atasoy, MD,1 Afag Aghayeva, MD,1 Onur Bayraktar, MD,1 Volkan Ozben, MD,1
Bilgi Baca, MD,1 Ismail Hamzaoglu, MD,2 and Tayfun Karahasanoglu, MD2

Abstract

Introduction: After its description in 1980, restorative proctocolectomy has become the procedure of choice for
ulcerative colitis (UC). The supposed advantages of the laparoscopy have proven beneficial for colorectal
operations but a standard technique in laparoscopic restorative proctocolectomy (LRP) is still lacking. In this
study, we present our technique of LRP with vascular high ligation (VHL) and embryological dissection (ED).
Materials and Methods: This retrospective study reviewed patients who underwent LRP with VHL for UC
from January 2009 to June 2015. Of these, only two-stage LRP patients were included to the study. The LRP
technique was performed by five ports through a medial-to-lateral approach. The dissection was carried out
between the embryological planes and all the vessel roots were highly divided. A diverting ileostomy was
performed in all of the patients.
Results: Forty-six patients were operated for UC with the laparoscopic approach. Among these patients, there
were 19 (8 females) patients who were performed LRP with VHL. The median age was 42 (range 25–62) years.
No intraoperative complications occurred. There was no conversion to open procedure. Early postoperative
complications were observed in 3 (15.8%) patients, including postoperative mechanical bowel obstruction
(n = 1), wound infection (n = 1), and ileal pouch bleeding (n = 1).
Discussion: High ligation of the vessels is not routinely performed except in the presence of malignancy. In our
study, we focus on the importance of high ligation and ED for better observation and preservation of the
important anatomical structures. According to our opinion, this approach aids in the preservation of the ureters,
nerves, and the duodenum providing better observation of dissection planes.

Keywords: ulcerative colitis, high ligation, embryological dissection, laparoscopy, restorative proctocolectomy

Introduction Besides, although with very small incidence, by this tech-

nique any incidental colorectal cancer could be treated at

I n the conventional surgical technique of restor-

ative proctocolectomy for ulcerative colitis (UC), the co-
lonic mesentery is resected near the intestinal wall with the
help of energy devices or surgical ties, without a need for
vascular high ligation (VHL), which is sometimes difficult in
the presence of previous inflammation sequelae.1
During laparoscopic restorative proctocolectomy (LRP),
we have noticed that clearer surgical field provided by per-
forming VHL and embryological dissection (ED) with me-
socolic/rectal dissection increases the observation of the
retroperitoneal structures, especially in the presence of severe
pericolonic inflammation.
the same surgical session without a need for further lym-
phadenectomy.2
In this study, we present our experience with VHL and ED
techniques in LRP for UC.
Materials and Methods
This retrospective study comprised patients with UC who
underwent LRP and ED between January 2009 and June 2015.
Patients before 2009 were not included since before that year we
were performing classical LRP without VHL. A shift to VHL
took place in the beginning of 2009. Among these patients, only

1
Department of General Surgery, Atakent Hospital, Acibadem University School of Medicine, Istanbul, Turkey.
2
Department of General Surgery, Maslak Hospital, Acibadem University School of Medicine, Istanbul, Turkey.

1
2 ATASOY ET AL.
two-stage (first stage: laparoscopic total proctocolectomy with
J-pouch and pouch-anal anastomosis with diverting loop
ileostomy; second stage: closure of loop ileostomy) LRP pro-
cedures were enrolled to the study. All patients who underwent
procedures other than two-stage laparoscopies were excluded
from the study. The medical records of all patients were re-
trieved from the patients’ files. Patient demographics, body
mass index (BMI), preoperative duration of disease, operation
time, blood loss, and complications were collected.
Surgical technique
The surgical procedure is performed through a medial-
to-lateral approach with standard laparoscopic instruments
through five ports. Our technique has been described in a
previous article.3 The dissection starts at the ileocolic vessels
that are clipped and transected at their origin. Staying be-
tween the embryological planes just anterior to the right
ureter, Gerota’s fascia, and duodenum, mesenteric dissection
is extended up to the root of the right colic artery (if present)
and the middle colic artery, which are transected between
clips near the superior mesenteric artery. After mobilization
of the right colon laterally, the terminal ileum is prepared and
transected with an endoscopic linear staple. With traction on
the transverse colon, the hepatic flexure is freed, the lesser sac
entered, and then the gastrocolic ligament divided. The dis-
section is continued along the transverse mesocolon, taking
down the splenic flexure. Position of the patient and the
surgical team was changed. On the left side, the peritoneum is
incised at the sacral promontorium and the aortomesenteric
window is opened, preserving the left ureter, gonadal vessels,
and autonomic nerves. Again the surgical procedure contin-
ues superficial to the Gerota’s fascia. The inferior mesenteric
vessels are clipped and divided. After lateral mobilization of
the left colon, total mesorectal excision follows in the holy
plane. Then, the rectum is transected with an endoscopic
linear staple. The specimen is extracted through a suprapubic
incision by enlarging of the suprapubic trocar site. Creation
of ileal pouch, stapled pouch-anal anastomosis, and planned
diverting loop ileostomy completes the operation.
After the operation, starting on postoperative day 1, patients
were asked to ambulate and to perform breathing exercises,
and the urinary catheter was removed. In addition, patients
who could tolerate liquids on postoperative day 1 were offered
solid food. Discharge criteria were tolerance of meals without
nausea or vomiting, established stoma function, adequate pain
control with oral analgesia, and independent ambulation.
Results
Between January 2009 and June 2015, 46 cases of UC un-
derwent restorative proctocolectomy, of which 28 were per-
formed laparoscopic, 17 open, and one robotic restorative
proctocolectomy. Of the 28 laparoscopic patients, 19 (8 fe-
males) underwent two-stage operations. Indications for sur-
gery were intractability to or complications of medical therapy
in 18 (95%) and synchronous right colon cancer in one (5%) of
the patients. The median age was 42 (range 25–62) years with
an average UC duration of 5 (range 1–18) years. The mean
BMI was 23 (range 16–34) kg/m2. The mean operative time
was 344 – 71 minutes (mean – standard deviation) and the
mean operative blood loss was 137 mL (range 40–600). There
was no conversion to open procedure. No intraoperative
complications occurred. Median follow-up period was 4
(range 1–7) years. Early postoperative complications were
observed in 3 (15.8%) patients, including postoperative me-
chanical bowel obstruction (n = 1), wound infection (n = 1),
and luminal pouch bleeding (n = 1). All surgical complica-
tions were treated conservatively. There was no mortality.
Discussion
Since January 2009, our LRP technique for UC had changed
from classical near-colonic dissection to VHL and ED. Ac-
cording to our limited experience, LRP with VHL of the mes-
enteric vessels and ED with mesocolic/rectal dissection for UC
are feasible and can be performed with good technical effi-
ciency. With increasing experience in laparoscopic colorectal
surgery for cancer, we have begun performing VHL and ED for
UC patients. It was our subjective experience that this approach
provided clearer ED planes and better surgical anatomy.
In patients with UC undergoing LRP, the mesocolon is
usually divided in a plane near the bowel wall to avoid in-
juries to the retroperitoneal structures such as the ureters,
gonadal vessels, duodenum, and autonomic nerves.4 How-
ever, dissection in this plane requires ligation of many mes-
enteric vascular branches and may sometimes be difficult in
the presence of chronic pericolonic inflammation.1 This may
bring some risks of harm to the underlying structures.
In our series, there was no mortality and no conversion to
open procedure. Overall complication rate was 15.8%, which
was comparable to the complication rates reported in the
literature.5
Dissection between embryological planes causes minor
blood loss and less tissue trauma. In addition, dissection under
direct vision of the retroperitoneal structures may ease their
preservation. Moreover, dissection close to the bowel wall
may leave some microabscesses within the mesocolon in ac-
tive colitis. Further studies comparing the technique men-
tioned and the classical technique are necessary to confirm
these hypotheses.
Our technique could be criticized as being an overtreatment
for a ‘‘benign’’ disease because the dissection carried out close to
the vascular pedicles could damage the autonomic nerves.4 Since
the internal anal sphincter receives excitatory innervation from
the thoracolumbar sympathetic nerves, damage to the lower
mesenteric ganglion and origin of the thoracolumbar plexus
could cause alteration in the internal sphincter function.6 In our
series, we did not encounter any injuries to the autonomic nerves.
The main limitation of our study was its retrospective
character. Another criticism of our approach might be that in
expense of better observation, it may cause longer operating
times and major vascular and autonomic nerve injury due to
close dissection.7 In our opinion, VHL and ED by increasing
the observation ease preservation of the retroperitoneal struc-
tures such as nerves, ureters, and the retroperitoneal vessels.
The operating time spent during the dissection between the
embryological planes in our technique could be similar to the
time-consuming near-colonic mesenteric dissection in the clas-
sical technique. Comparative studies may clarify these concerns.
In a study reported by Remzi et al., the incidence of co-
existing colorectal cancer in UC patients was nearly 4%.
Of these patients, 10% were incidentally diagnosed.8 This
information could bring a question in mind about the benefit
of complete mesocolic surgery for a disease with 0.4%
LAPAROSCOPIC SURGERY IN ULCERATIVE COLITIS
incidental colorectal carcinoma. To advise a routine VHL in
LRP with this incidence rate is open to discussion. In our
series, we did not face any incidental colorectal carcinoma.
Future studies comparing ours and the standard approaches
regarding the operating time, blood loss, complications, sexual
function, and hospital stay may make it clear whether the
presented technique has advantages or not.
Conclusions
LRP with VHL and dissection through the embryological
planes can be successfully performed with satisfactory out-
comes to treat UC. According to our opinion, providing better
observation of dissection planes, this approach aids in the
preservation of the retroperitoneal structures. Further compar-
ative studies are required before the VHL and ED techniques
can be recommended as a regular approach in LRP for UC.
Acknowledgment
The authors gratefully acknowledge the assistance of Ebru
Kirbiyik in data collection for the preparation of this article.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Deniz Atasoy, MD
Department of General Surgery
Atakent Hospital
Acıbadem University School of Medicine
Halkalı merkez mh.
Turgut Özal bulvarı No:16
Küçükçekmece
Istanbul
Turkey
E-mail: datasoy@gmail.com