Minimally Invasive and Robotic Surgery for Ulcerative Colitis

Abstract

Significant advancements have been made over the last 30 years in the use of minimally invasive techniques for curative and restorative operations in patients with ulcerative colitis (UC). Numerous studies have demonstrated the safety and feasibility of laparoscopic and robotic approaches to subtotal colectomy (including in the urgent setting), total proctocolectomy, completion proctectomy, and pelvic pouch creation. Data show equivalent or improved short-term postoperative outcomes with minimally invasive techniques compared to open surgery, and equivalent or improved long-term bowel function, sexual function, and fertility. Overall, while minimally invasive techniques are safe and feasible for properly selected UC patients, surgeons must remember to abide by the principles of high-quality proctectomy and pouch creation and convert to open if necessary.

Despite significant advancements in medical treatments for ulcerative colitis (UC), approximately 30% of patients with UC continue to require surgical resection. ¹ Indications for surgery are primarily severe disease refractory to medical therapy, dysplasia, fulminant colitis, toxic megacolon, or colon perforation. ² Many of the operations for medically refractory UC are being performed in three stages, starting with total abdominal colectomy, followed by completion proctectomy, ileal pouch anal anastomosis (IPAA), and diverting loop ileostomy, and finally, ileostomy closure. ³ Given that rates of UC have been increasing, decision-making regarding the performance of these curative and restorative operations has become increasingly important. ¹

While minimally invasive (MIS) techniques have become widely accepted by colorectal surgeons ever since the first description of laparoscopic colectomy in 1991, ⁴ the uptake of laparoscopic and robotic approaches for inflammatory bowel disease (IBD) surgery has progressed slowly. ^{5 6 7} This could be due to the fact that IBD patients are often malnourished, hypoalbuminemic, anemic, and in a catabolic state with inflamed and friable tissues. ¹ Furthermore, IBD operations can be complex, making some surgeons hesitant to employ MIS techniques, as there is a high conversion rat, even in the hands of expert IBD and MIS surgeons. ^{5 8}

Nevertheless, numerous studies have demonstrated that MIS techniques are safe in properly selected UC patients, in both the elective and urgent setting. ^{1 5 9} Peters published one of the first descriptions of laparoscopic total proctocolectomy in two UC patients in 1992. ¹⁰ The same year, Wexner et al published one of the first case–controlled comparisons of laparoscopic versus open total abdominal colectomy with ileorectal anastomosis and total proctocolectomy with IPAA, finding that laparoscopy was safe, with comparable rates of ileus and length of stay, though longer operative times. ¹¹ Since then, MIS techniques have become increasingly utilized for IBD surgery. ¹²

Advantages and Disadvantages of Minimally Invasive Techniques

MIS techniques such as laparoscopy and robotics were developed as part of a general effort to “minimize surgical trauma.” ⁵ Numerous studies have demonstrated the benefits of MIS approaches compared to open surgery, including less postoperative pain, shorter length of stay, and decreased rates of incisional hernias. ^{13 14 15} Furthermore, MIS techniques are associated with less intra-abdominal adhesions and thus fewer future small bowel obstructions, a particularly important consideration given the young age of most UC patients. ¹⁶ Less intra-abdominal adhesions can also make subsequent operations, such as completion proctectomies and J-pouch creations, easier and more likely to be possible with MIS techniques. ¹ MIS approaches are also associated with improved cosmesis in the IBD population, with patients reporting better body image and higher satisfaction with cosmetic results. ¹⁷

Laparoscopy has many advantages, including the fact that it has become an essential part of the training and practice of colorectal surgeons. Surgeons who are adept at laparoscopic segmental colectomies and proctectomies for colorectal cancer and diverticulitis can apply those same skills for patients with UC. In cases with friable tissues and/or difficult exposure, a hand port can be placed through the future specimen extraction site, and the surgeon can use one hand to assist with the operation. ¹⁸ Compared to robotics, laparoscopy is faster to set up and complete an operation, ¹⁹ can be done with fewer ports, and is easier to perform in thin patients.

Robotics was introduced in the early 2000s, first adopted by urologists and gynecologists and then expanded to other surgical subspecialties. Robotic platforms offer many advantages including three-dimensional visualization, 10× magnification, third arm retraction, a fixed camera, wristed instrumentation, and improved surgeon ergonomics. ¹⁹ These characteristics have proven particularly beneficial in the fixed, tight space of the pelvis. Compared with laparoscopy, robotics has been associated with a faster learning curve and improved complex task performance with decreased operator workload. ²⁰ Furthermore, some surgeons report being more likely to attempt and complete an operation minimally invasively with the robot than with laparoscopy. ¹⁹

Nevertheless, disadvantages of robotic techniques include longer operative times and higher associated costs with no proven differences in postoperative outcomes when compared to laparoscopy. ^{21 22} Additionally, for both laparoscopy and robotics, patients must be able to tolerate insufflation and steep Trendelenburg positioning for prolonged periods of time, which would exclude most patients with septic shock and/or severe comorbidities. ²³

Laparoscopic and Robotic Subtotal Colectomy: Safety

Numerous studies have demonstrated that laparoscopic compared to open subtotal colectomy (STC) is safe and often associated with improved outcomes. Bartels et al performed a systematic review and meta-analysis comparing laparoscopic versus open STC with end ileostomy for nontoxic colitis, including nine nonrandomized studies that comprised 966 patients. ²⁴ They found that the laparoscopic procedures were associated with decreased wound infections, decreased intra-abdominal abscesses, and shorter length of stay. There was a 5.5% rate of conversion to open. ²⁴

Causey et al utilized the American College of Surgeons National Surgical Quality Improvement Program database to compare laparoscopic versus open colectomies for UC. ¹² They found that laparoscopic procedures tended to have fewer surgical site infections, pneumonias, and need for transfusions. Between 2005 and 2008, utilization of laparoscopy for colectomies for UC increased by 8.5% each year. ¹² Laparoscopic STC is safe even in urgent and emergent settings, as demonstrated by a study of 90 patients by Telem et al, which found longer operative times associated with laparoscopic procedures, but decreased intraoperative blood loss and decreased wound complications, and no difference in overall morbidity, readmission, or reoperation. ²⁵ Furthermore, some studies have even shown earlier restoration of intestinal continuity after laparoscopic STC compared to open. ²⁶

In terms of the robotic platform, data have also shown the feasibility and safety of robotic STC for UC, with fewer conversions to open, earlier return of bowel function, and shorter length of stay compared to laparoscopic STC. ^{9 27} One study comparing open, laparoscopic, and robotic elective total abdominal colectomies found that laparoscopic cases had a 13.3% rate of conversion to open, compared to 1.5% for robotic ( p  < 0.01). ²² Even in the urgent setting, early data by Anderson et al show that urgent robotic STC ( n  = 6) for severe UC has comparable perioperative outcomes to laparoscopic STC ( n  = 13) and only took 29 minutes longer on average. ⁶ An analysis of the Nationwide Inpatient Sample did show that robotic STC had higher costs than laparoscopic STC, with a mean difference in total hospital charges of $15,595 ( p  < 0.01). ²²

The development of the DaVinci Xi (Intuitive Surgical Inc., Sunnyvale, CA) platform has enabled expansion of robotic applications from primarily the pelvis to the abdomen, specifically for multiquadrant work like what is necessary for STC. ⁹ With “Table Motion Technology,” the ability to move the camera from port to port, nearly 360-degree boom rotation, patient clearance, and longer instrument shafts, more surgeons have begun utilizing the robotic approach for STC for UC.

Laparoscopic and Robotic Subtotal Colectomy: Tips and Tricks

Many of the same considerations for open STC also apply to MIS STCs, including whether to start the dissection from the left colon and proceed to the right (or vice versa) and whether to perform the dissection in a medial-to-lateral fashion or lateral-to-medial. Similarly, management of the rectal stump (whether to leave an abdominal drain by the stump, place a rectal tube, implant the rectal stump above the fascia, etc.) is more dependent on tissue quality and surgeon preference, not surgical approach. When performed, the rectal stump can be implanted in the lower aspect of the midline incision for open cases, or at the Pfannenstiel or lower midline extraction site for MIS cases. ²⁸

One decision specific to MIS approaches is how to transect the rectosigmoid colon. While many surgeons use laparoscopic or robotic staplers through the right lower quadrant port to transect the specimen, some surgeons transect the specimen open through a Pfannenstiel or lower midline extraction site with a contour curved stapler (Ethicon) or thoracoabdominal (TA) stapler (Medtronic). When the rectosigmoid is transected intra-abdominally, an additional option for extraction site is the ileostomy site. Sometimes in order to get the bulky colon out, the fascial and skin incisions of the stoma site need to be slightly enlarged. In these cases, a suture at the corner of the fascial incision can tighten the parastomal defect and a purse-string suture in the dermal skin layer can tighten the skin opening, if needed.

For robotic STC, most surgeons utilize a “double-docking” technique in which they start on either the left or right colon, do as much of the dissection as possible, and then undock the robot, flip the boom 180 degrees, and redock to complete the operation. ^{6 9} For example, surgeons who start on the left mobilize the sigmoid and descending colon and take down the splenic flexure (often needing to rotate the robotic arms toward the patient's head, readjusting the arm distance and flexible joints to avoid collisions), going as proximal as possible before undocking, rotating the boom, redocking, and then completing the ascending colon and hepatic flexure dissections. Limiting switching between abdominal quadrants is key to minimizing operative times.

Laparoscopic and Robotic Proctectomy: Safety

MIS approaches were adopted more slowly for rectal UC operations than colon UC operations due to the increased complexity of pelvic dissections, similar to MIS trends for malignant colorectal indications. ⁵ Proctectomy for UC can be performed at the same time as colectomy, as a total proctocolectomy, or after STC, as a completion proctectomy, with or without simultaneous creation of an IPAA. Numerous studies have again demonstrated the safety and feasibility of MIS proctectomy, including an early study from Cleveland Clinic that examined outcomes of laparoscopic versus open proctectomy after a laparoscopic STC for UC. ²⁹ They found that laparoscopic proctectomy was associated with fewer adhesions, reduced length of stay, and longer operating time, with no differences in complication rate, pouch function, or quality of life.

Laparoscopic and robotic techniques offer improved visualization and preservation of the autonomic nerves in the pelvis that control bowel, urinary, and sexual function, particularly important given the young age of many UC patients. ¹ Furthermore, decreased inflammation and adhesion formation around these nerves and female reproductive organs after MIS operations may confer improved fertility compared to open surgery, a finding that was confirmed by a study that showed significantly increased pregnancy rates in female patients who underwent laparoscopic restorative proctocolectomy compared to open. ³⁰ In male patients, robotic rectal surgery has been found to be associated with improved voiding and sexual function compared to laparoscopic surgery. ³¹

Therefore, completion proctectomy or total proctocolectomy for UC is safe to perform with a MIS approach. Nevertheless, the same principles apply regardless of approach. Patients who are undergoing staged operations must be fully optimized before proceeding with the second stage, including weaning off steroids and other immunosuppressing medications and improving their nutritional and functional statuses.

Laparoscopic and Robotic Proctectomy: Tips and Tricks

MIS techniques for proctectomy for UC are similar to those previously described for rectal cancer operations. One exception is that some IBD surgeons prefer intra-mesorectal dissections for UC, due to a theoretical benefit of improving preservation of the pelvic nerves. ³² Total mesorectal or intra-mesorectal dissections are possible regardless of surgical approach, due to the development of advanced electrosurgical vessel-sealing instruments. Within the confines of the bony pelvis, where rectal dissection often causes pooling of interstitial fluid and blood as well as smoke from electrocautery, the use of an assistant with a suction device is key. In laparoscopy, the assistant could also assist by pulling the rectum out of the pelvis, which could be achieved by third arm retraction if the robotic platform is being used.

Another consideration is that instead of just “straight-stick” laparoscopy, a hand-assist port can be placed to assist with dissection or to perform part of the proctectomy in an open approach. ¹³ In these laparoscopic hand-assisted procedures, the hand port is often placed through a Pfannenstiel incision or lower midline incision. ³³ The hand-assist port can also be used for extraction of the proctectomy specimen. Other options for extraction sites in MIS proctectomy also include the ileostomy site as well as transanally.

Perhaps the most controversial aspect of MIS proctectomy is how best to transect the distal rectum such that the rectal cuff is appropriately short, just above the anal canal and levator complex, to decrease the risk of future proctitis or dysplasia in the cuff. ¹ One option is to use an articulating laparoscopic or robotic stapler, often through a right lower quadrant port. ³⁴ Due to the narrow pelvis, 45 mm long staplers are often used, articulated after passing the pelvic inlet, with the stapler jaws pointed straight down, while the assistant or surgeon retracts the rectum out of the pelvis. A nonsterile assistant can also apply perineal pressure to help with transecting the specimen appropriately low. Despite these maneuvers, two to three stapler firings are often needed to fully transect the rectum, ³⁴ which is not ideal given that increasing overlapping staple lines have been associated with anastomotic leaks. ³⁵ Common pitfalls to transecting the distal rectum with MIS staplers are transecting too high and leaving too long of a cuff (particularly if the surgeon is attempting to achieve a single stapler fire) and transecting the rectum obliquely, leaving a long staple line that could increase the risk of anastomotic leak. ¹

Because of these limitations, another option for transecting the rectum is to perform it open through a lower midline or Pfannenstiel incision, using a contour or TA stapler. This option is particularly appealing if a hand port has already been made or if the surgeon is planning on extracting the specimen through one of these incisions. An additional option for rectal transection is to evert the rectum transanally and cut the rectum above the dentate line using electrocautery, a particularly appealing option if the surgeon is planning to do a rectal mucosectomy with a handsewn IPAA. Above all else, the surgeon must abide by the usual principles of safe surgery and be willing to convert to open if needed to achieve a better quality proctectomy or rectal transection.

Laparoscopic and Robotic Ileal Pouch anal Anastomosis: Safety

Since the first laparoscopic IPAA was described in the 1990s, ³⁶ MIS techniques have been slowly adopted for pouch creation. Prior data confirm the safety and feasibility of laparoscopic IPAA, with longer operative times than open surgery but comparable complication rates, faster postoperative recovery times, improved cosmesis, and decreased impact on fertility and sexual function. ^{13 19} When comparing robotic to laparoscopic IPAA, a systematic review and meta-analysis by Flynn et al found that robotic cases were associated with longer operative times, decreased estimated blood loss, and decreased length of stay, with no difference in complication rates, readmission rates, time to first bowel movement, functional outcomes, or quality of life. ¹⁹ There were no differences in rates of conversion to open (4% in robotic cases, 3% in laparoscopic cases) or rates of anastomotic leak (ranged from 6 to 33% in robotic cases, 3 to 29% in laparoscopic cases). ¹⁹

In terms of long-term bowel function, studies have shown similar or improved bowel function after MIS IPAA compared to open. In a systematic review and meta-analysis by Singh et al comparing laparoscopic versus open IPAA, laparoscopic cases were associated with significantly fewer nocturnal bowel movements and decreased pad usage, with no differences in number of daily bowel movements or pouch failure rates. ³⁷ Ultimately, long-term pouch function is most dependent on whether anastomotic leak and/or pelvic sepsis occurred ⁵ ; while these rates are similar overall for open versus MIS IPAA patients, ^{19 37} MIS IPAA does have a learning curve in which rates of pelvic sepsis are higher when operations are performed earlier in a surgeon's experience. ³⁸

Of note, in a review by Schwartzberg and Remzi, they describe seeing an increasing number of patients who underwent MIS IPAA who require redo pelvic pouches. ¹ They state that “minimally invasive pouches have … been responsible for a number of mechanical defects, such as retained rectums, ischemic strictures, and/or pouch twists that ultimately require operative correction.” Anderson and Grucela explain that failure of laparoscopic pouches could be due to difficulties of straight-stick laparoscopy in the pelvis, because of the need to look over the sacral promontory and work in very limited space. ⁹ They suggest that robotic platforms may help overcome these limitations, particularly in patients who are male and obese. These observations by expert IBD surgeons emphasize the importance of adhering to traditional principles of proctectomy and pouch creation, regardless of surgical approach. If surgeons have any concerns about rectal transection, pouch reach, or pouch creation, they should have a low threshold to convert to open, especially early in their learning curve.

Laparoscopic and Robotic Ileal Pouch anal Anastomosis: Tips and Tricks

Like in open IPAA, the first decision point of a staged MIS IPAA is whether to start the operation with the ileostomy takedown and pouch creation, or the completion proctectomy. Surgeons who start with ileostomy takedown often place a Gelpoint Path (Applied Medical) in the ileostomy aperture and then insufflate, ⁹ while others place a wound protector that they twist around a laparoscopic or robotic port and make the skin incision airtight with penetrating towel clips before insufflating. They then mobilize the small bowel mesentery, before turning their attention to the completion proctectomy as discussed above.

Most surgeons make the pouch through the same incision that they use to extract the proctectomy specimen. Options include a Pfannenstiel or lower midline incision, which offers the opportunity to do part of the proctectomy open if desired. Another option is through the ileostomy site, ⁹ which leaves the patient with fewer and smaller incisions. Currently, most surgeons make the pouch in an open fashion, with the small bowel exteriorized, though there have been early reports of fully intracorporeal creation of J-pouches. ³⁹

One of the most important aspects of pouch surgery, regardless of approach, is assessing and maximizing pouch reach. The principles and maneuvers are the same for open and MIS IPAA, such as fully mobilizing the small bowel mesentery laparoscopically or robotically along the superior mesenteric artery (SMA) up to and under the duodenum and pancreas. ⁴⁰ High ligation of the ileocolic pedicle can also be performed laparoscopically or robotically, and the peritoneum over the SMA and small bowel mesentery can be scored after exteriorizing the small bowel. Trialing descent of the ileal loop into the deep pelvis by grasping the future pouchotomy and ensuring that it reaches below the pubis is extremely important and can be done through the extraction site. More proximal bowel can also be tested to see if there is improved reach. If there are any concerns about pouch reach, surgeons must be willing to convert to open if needed to perform these maneuvers safely. ¹

Next, the pouch is placed back in the abdomen, which is reinsufflated. The surgeon again verifies that the pouch reaches the deep pelvis and also ensures that the pouch is not twisted, by confirming that the cut edge of the mesentery is straight and that there is no small bowel beneath the pouch mesentery. ⁴⁰ The proximal small bowel should be retracted up into the patient's left abdomen. The surgeon holds the pouch in the proper orientation as the assistant slowly closes the EEA stapler to ensure that the pouch does not twist during stapler closure. A flexible sigmoidoscopy or air leak test with a bulb suction may be performed in a manner similar to open surgery.

Transanal Ileal Pouch anal Anastomosis

In order to address the issues of rectal transection using MIS techniques, multiple groups have begun performing transanal IPAA (taIPAA), ⁴¹ a technique that originated from the development of transanal total mesorectal excision (taTME) for rectal cancer. ⁴² Similar to the taTME, a transanal access platform (such as the Gelpoint Path, Applied Medical) is placed, purse-string suture is used to close the rectum, and pneumorectum is achieved, the distal rectum is transected about 3 cm above the dentate line, and rectal dissection continues proximally until it joins the transabdominal rectal dissection. ⁴¹ The J-pouch is then created and a purse-string suture is placed at the base of the pouch around an anvil. A second purse-string suture is placed on the rectal cuff, and therefore a single-stapled double purse-string IPAA is created. ⁴¹ In this way, taIPAA offers a more accurate rectal transection without the need for multiple staple firings. Early studies have demonstrated similar or decreased postoperative morbidity in taIPAA patients compared to other MIS IPAA patients. ^{41 43} TaIPAA patients have comparable quality of life and bowel, urinary, and sexual function, ⁴⁴ though these data are preliminary and based on small case series. Overall, it appears that taIPAA offers improved visualization and access during the low pelvic dissection, likely lower conversion rates, and similar postoperative and functional outcomes. ⁴⁵ Despite the theoretical benefit of improving the rectal transection and avoiding multiple stapler firings, there does not appear to be a difference in rates of anastomotic leak, ^{41 46} though future studies with larger sample sizes are needed to better evaluate this new technique. ⁴⁵

Conclusion

In the properly selected patient, MIS approaches to STC, proctectomy, and IPAA in patients with UC are safe, feasible, and growing in popularity, and may offer improved outcomes compared to open surgery. Nevertheless, patients who are in septic shock, with perforated colons, severe comorbidities that preclude abdominal insufflation or steep Trendelenburg positions, or expected to have dense intra-abdominal adhesions are unlikely to be good candidates for MIS techniques. Surgeons must place the integrity of the proctectomy and IPAA creation over their desire to perform the operation minimally invasively and have a low threshold to convert to open if needed to improve the safety or quality of the procedure.