Evolution of practice of robotic ileoanal pouches: a single-center case series in East London

Abstract

Robotic ileal pouch-anal anastomosis offers improved ergonomics and dexterity, leading to increased use. This study presents our initial series, describing technique and outcomes from a nationally accredited district general hospital. Data of consecutive patients who underwent robotic restorative proctocolectomy, between January 2021 and August 2024 was presented. Da Vinci Xi system (Intuitive Surgical) was used for all cases. We usually use the ileostomy site as the extraction site and J pouch formation avoiding Pfannenstiel or lower midline incision. Eight patients with a median age of 38 years, and a mean body mass index of 20.65 kg/m² were included. Four had restorative proctectomy while one had restorative proctocolectomy. The median operative time was 407.5 minutes. One patient needed reoperation due to intra-abdominal collection. The median length of stay was 6.5 days. One readmission was for adhesive obstruction. There were no mortalities. Our series demonstrates the technical feasibility and safety of our robotic technique.

INTRODUCTION

Ileal pouch-anal anastomosis (IPAA) is the procedure of choice for patients with chronic ulcerative colitis (UC) and familial adenomatous polyposis (FAP), restoring intestinal continuity and improving the quality of life (QoL). With an increase in operative experience, the surgical outcomes of these patients continue to improve. The main goal of treatment is to construct a well-functioning pouch [1].

Along with improved operative experience, there has also been an evolution of operative techniques, with the adoption of a minimally invasive approach, including the use of a robotic platform [2]. The adoption of a minimally invasive approach has been due to the benefits of better cosmesis, shorter convalescence, decreased intra-abdominal adhesions, and reduced rate of incisional hernias [3].

Limitations of the laparoscopic approach are the limited range of motion within a narrow pelvis and confined visibility during rectal dissection and anastomosis. The robotic approach provides improved ergonomics, and dexterity due to a wide range of wristed movements, and a stable platform, while resulting in equivalent safety and efficacy outcomes resulting in increased application in rectal surgery. Another advantage offered by the robotic system is the surgeon-controlled camera. The DaVinci (Intuitive Surgical, Inc.) can detect surgeons’ hand movements, thereby eliminating physiological tremors.

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) has implemented standards for pouch surgery centers to achieve accreditation. These standards include a minimum number of pouch procedures, a two-surgeon operating team, a dedicated pouch nurse, an inflammatory bowel disease (IBD) multidisciplinary team, and an IBD hot clinic. Currently, only 22 units in the United Kingdom have obtained this accreditation. Centralization of pouch services to high-volume centers has been proposed as a strategy to enhance long-term outcomes and reduce pouch failure rates.

Our unit at a busy district general hospital (DGH) started pouch services in 2018 which had been developed over many years. We started robot-assisted pouch surgery in 2020. We present our initial series of robotic IPAA performed at our unit.

CASES REPORT

Patients’ information and surgical setting

All patients undergoing robotic restorative proctocolectomy or restorative proctectomy for UC/FAP were included. Our hospital is a large DGH (under the National Health Service) in England, serving a population from a wide range of social and ethnic groups across North East London. Our Pouch service was initiated in 2018 and has been developed over many years. The service is run by two colorectal consultants. We started with robotic pouch surgery in 2021. Our service is well-equipped to manage pouches according to the guidelines on the treatment of UC.

Restorative proctocolectomy

A two-stage surgical procedure for patients with conditions like UC or FAP. It involves the complete removal of the colon and rectum, followed by the creation of an ileal pouch-anal anastomosis. The first stage typically includes the creation of a diverting stoma, and the second stage involves closure of the stoma once the pouch has healed.

Restorative proctectomy

A surgical procedure for patients who have previously undergone a subtotal colectomy with an end ileostomy. It involves the removal of the remaining diseased rectum, the creation of an ileal pouch-anal anastomosis, and the establishment of a diverting stoma. This is often considered a three-stage approach.

Clinical findings and timeline

Data of consecutive patients who underwent robotic restorative proctocolectomy via two- or three-stage between January 2021 and August 2024 were collected from a prospectively maintained database. The last follow-up was recorded up to August 2024.

Data was collected from a prospectively maintained dataset. Demographic information (age, sex, American Society of Anesthesiologists [ASA] physical status grade), operative factors (date, procedures, operative times, conversions, emergency setting), length of stay (LOS), postoperative critical care admission and short-term postoperative complications were recorded. Patients undergoing subtotal or total colectomy without restoration and an end-ileostomy or ileorectal anastomosis without pouch were excluded from the study. Postoperative in-hospital morbidity data were recorded according to Clavien-Dindo classification. Postoperative LOS and reoperations were also evaluated.

Therapeutic intervention (surgical technique)

Robotic proctocolectomy/proctectomy

Pneumoperitoneum is established via Veress needle insufflation or open access through a stoma site using an Alexis wound retractor (Applied Medical Resources Corp.). Port placement is depicted in Fig. 1. A 12-mm assistant port (Airseal, Applied Medical Resources Corp.) is inserted performing optical entry. Three 8-mm and one 12-mm robotic ports are placed in an oblique line from the right anterior superior iliac spine to the left subcostal margin. For right-sided colon procedures, the patient is positioned at 10° to 15° head-up tilt, with the right side elevated at 10°. The robot is docked, targeting the right upper quadrant to the colonic hepatic flexure. We prefer a clockwise approach where dissection begins with caecum continuing with ascending colon, and transverse colon. Appropriate vessels are controlled using a combination of robotic clips and advanced bipolar energy. Mobilization of the colon continues until splenic flexure is mobilized from the cranial aspect. Integrated table motion is used to facilitate this dissection by adjusting the patient's position depending on the view we would like to achieve. For the left-sided colon and pelvic part of the procedure, the patient is positioned 23° head-down and 10° left side up. The robot is re-docked, targeting the left pelvic brim. The inferior mesenteric vein and artery are divided and the total mesorectal excision (TME) plane is followed. The rectum is dissected up to the pelvic floor, identifying and safeguarding the left ureter. We transect after a digital rectal exam to check position and height and angle usually 1.5 to 2 cm from the anal verge. This is performed anteroposterior and usually with two firings of the SureForm 45 blue cartridge (Intuitive Surgical, Inc.). The advantage is that it allows 60° of angulation each way, rather than 45° with most laparoscopic staplers. The height and angulation are far better than with open devices. In cases where previous subtotal colectomy was performed and restorative proctectomy only is needed access to the peritoneal cavity is done through the ileostomy site using Alexis retractor. Subsequently, other robotic ports are inserted in a similar manner as described above. The robot is docked and targeted. A standard robotic TME is performed. Pouch-anal anastomosis is performed using a powered circular stapler (CDH 29, Ethicon).

Fig. 1.

Trocar placement for robotic ileal pouch-anal anastomosis using the Da Vinci Xi system (Intuitive Surgical, Inc.). Ports 1, 2, and 4 are 8-mm robotic ports. Port 3 is a 12-mm robotic port used with a reducer unless stapling is required. Port A indicates the assistant port, placed 7 cm perpendicular to the midpoint between ports 3 and 4. The spacing between each port is 6–8 cm. MCL, midclavicular line.

J pouch fashion

The J pouch is created using the staple technique. The terminal ileum is extracted through an ileostomy extraction site protected by the Alexis retractor. This way no Pfannenstiel or lower midline is required so the only scars apart from the stoma reversal, the patient is left with, are the port sites. The ileum is folded into two limbs for the pouch length measures between 15 to 20 cm ensuring a tension-free anastomosis is feasible to perform. We are looking for the apex of the pouch to reach beyond the lower border of pubic symphysis. The terminal ileal end staple line is buried with interrupted sutures. An enterotomy is created on the antimesenteric aspect of the apex of the two folded ileal segments. A side-to-side anastomosis of the two portions of terminal ileum is created using two to three firings of a 75-mm linear stapler, ensuring the posterior small bowel mesentery is excluded. Interrupted sutures are placed along the length of the staple line externally. A 2-0 polypropylene purse-string suture is made at the margin of the enterotomy to secure the anvil of the circular stapler at the apex of the pouch, and this is returned to the peritoneal cavity. Pouch-anal anastomosis is performed using a powered circular stapler (CDH 29).

When extracting the specimen via the ileostomy site, if a larger aperture is required, we extend the ileostomy incision laterally. This is closed primarily, but if a parastomal hernia develops, it would be definitively repaired at the time of stoma closure without a mesh.

To prevent potential complications, it is crucial to ensure the J pouch is free of torsion. The use of seromuscular marking sutures aids in identifying any twisting, as they provide visual cues during robotic pelvic visualization. However, a complete 360° rotation must be rigorously excluded.

When loading the pouch and anvil onto the circular stapler, meticulous inspection of the mesenteric cut edge is essential to confirm the absence of torsion and internal herniation of the small bowel.

To address potential reach limitations, surgical techniques such as mesenteric scoring, ileocolic artery ligation, or creating windows in vascular arcades can be employed to optimize tissue mobilization and achieve adequate pelvic reach.

Statistical methods

All data was collected using a Microsoft Excel spreadsheet 2016 (Microsoft Corp.). Continuous data was expressed as a median with an interquartile range. All variables were expressed as a number and a percentage.

Clinical and surgical outcomes

Our case series comprises eight patients who underwent robotic IPAA surgery. Their demographical data is presented in Table 1. One patient undergoing restorative proctocolectomy needed conversion to open due to uncontrolled bleeding. The median age of patients was 38 years, with a mean body mass index of 20.65 kg/m². All patients were ASA grade II. The most common indication for surgery was UC. Robot-assisted surgery took a median duration of 407.5 minutes (Table 2). All patients had a defunctioning ileostomy. Additionally, we have also performed two robotic completion proctectomies. One patient had an intra-abdominal collection postoperatively which required a surgical washout. The median LOS was 6.5 days. Only one patient needed readmission for adhesive small bowel obstruction. There were no mortalities (Table 3).

Table 1.

Patient demographics

Demographics	Data
No. of patients	8
Age (yr)	38 (21–48)
Sex, male:female	6:2
Body mass index (kg/m2)	26.2 (23.4–30.9)
ASA PS classification
II	8 (100)
III	0 (0)
Indication of surgery
UC	6 (75.0)
FAP	1 (12.5)
UC + rectal cancer	1 (12.5)

Values are presented as number only, median (interquartile range), or number (%).

ASA, American Society of Anesthesiologists; PS, physical status; UC, ulcerative colitis; FAP, familial adenomatous polyposis.

Table 2.

Operative data

Type of surgery	Data (n = 8)
Restorative proctectomy	6 (75.0)
Restorative proctocolectomy	2 (25.0)
Defunctioning ileostomy	8 (100)
Duration of surgery, median (min)	407.5
Blood loss, median (mL)	50
Conversion	1 (12.5)

Values are presented as number (%) or median only.

Table 3.

Postoperative outcomes

Outcome	Data (n = 8)
Clavien-Dindo classification
I	2 (25.0)
II	1 (12.5)
III	0 (0)
IV	1 (12.5)
Length of stay (nights)	6.5 (4–27)
30-day readmission	1 (12.5)
30-day reoperation	1 (12.5)
Mortality	0 (0)

Values are presented as number (%) or median (interquartile range).

DISCUSSION

The adoption of the robotic platform in colorectal surgery is increasing. We describe the experience of an ACPGBI-recognized center that has adopted the robotic platform for pelvic dissection and IPAA procedures. Using our surgical technique we demonstrate safety and efficiency within this case series.

Robotic surgery has been shown to be safe and feasible in performing low anterior resections, thereby increasing use and applicability in rectal cancer surgery [4]. However, robotic proctectomy with IPAA is yet to gain momentum. Robotic surgery has inherent advantages conferred due to the technology, making it feasible to use in narrow areas like the pelvis due to its three dimensional vision and zoom, along with providing 7° of motion due to the endo-wrist technology. It also eliminates the tremors observed in open and laparoscopic surgery. The median duration of surgery in our series was 407.5 minutes which is similar to that reported in recent studies [5]. With increasing operative experience, there will be a resultant decrease in operative time was shown in a study by Miller et al. [2] where later procedures (robotic proctectomy-IPAA) were not significantly longer than their laparoscopic equivalent. Byrn et al. [6] and Mark-Christensen et al. [7] also demonstrated a trend toward a decrease in total procedure time for robotic procedures over the course of their studies. As newer platforms develop and with the adoption of hybrid techniques utilizing laparoscopic along with robotic techniques, the operative time is likely to reduce further as will the necessity of multiple docking and undocking.

Pouch surgery is a complex and intrinsically morbid operation. Because of this morbidity, the benefit between laparoscopic and robotic surgery may be less than that observed between laparoscopic and open surgery. Gebhardt et al. [8] found no difference in 30-day complication rates between robot-assisted and laparoscopic proctectomy with IPAA. Our series reports similar complication rates with those reported in the literature [9]. There was one 30-day reoperation. No mortality amongst our patients. Our series included two patients with CD II and IV complications. One was readmitted within 30 days for an adhesional small bowel obstruction that resolved with conservative management. The second patient developed a large presacral collection requiring a laparoscopic washout.

The expense of acquiring and maintaining the robotic platform is significant, which can potentially limit its widespread use. The operational life and utilization of the robot per year must also be considered. Gebhardt et al. [8], in their retrospective study, found an increase found a median higher total inpatient cost of 1.808 EUR per robot-assisted proctectomy. However, lower 30-day postoperative complication rates and shorter LOS may translate into overall reduced costs with the use of robotic surgery. Additionally, as there is an increase in the competitors with new robotic platforms entering the market, it is likely that acquisition, maintenance, and instrument costs will decrease over time.

The ultimate goal of IPAA is to ensure well well-functioning pouch. A particular concern amongst women is the reduction in fecundity. The superior vision offered by the robotic camera makes it easier to identify the pelvic autonomic nerves, thereby avoiding inadvertent injury. Miller et al. [2] found no difference in sexual function between patients undergoing robotic and laparoscopic pouch surgery. Another concern is pouch-anal anastomotic stricture, which can occur in 10% to 17% of patients in 6 to 9 months postoperatively [10]. Hand-sewn anastomosis is associated with higher stricture rates as compared to stapled anastomosis [10]. We perform a stapled anastomosis using a circular stapler. There is no reported difference in incidence rates of stricture formation reported with the use of 28- to 29-mm or 31- to 33-mm staplers [10]. Additionally, higher rates of strictures develop in patients with postoperative pelvic abscess or fistula. None of our patients have developed pelvic sepsis or strictures to date.

Unlike cancer surgery, pouch surgery primarily aims to improve the QoL for young patients and avoid the morbidity of a permanent ileostomy. The concept of patient counseling and shared decision-making is fundamental, along with individualized treatment strategies based on careful patient selection and multidisciplinary counseling (often involving patient support groups). As with any surgery primarily focused on improving QoL rather than removing malignancy, the surgical goals are to enhance patient QoL outcomes, reduce morbidity, and minimize the negative impact on QoL post-surgery. The development of robotic techniques provides colorectal surgeons with the opportunity to help patients achieve these goals.

This study’s limitations include a small sample size and a single-center experience, which may limit the generalizability of findings to broader patient populations and practice settings. The procedure requires specialized knowledge and a learning curve. Additionally, with increased competition and technological advancements, the cost of robotic surgery is likely to decrease over time. While this study has demonstrated the feasibility of pouch surgery, further research is needed to evaluate long-term functional outcomes and QoL data, which are essential metrics for any center considering this surgical approach.

Our series has looked at the postoperative outcomes after robotic IPAA. It is imperative to assess the long-term pouch function and impact on QoL in this young cohort of patients to understand the advantages of robotic surgery over the open and laparoscopic approach.