Total laparoscopic proctocolectomy and laparoscopy-assisted proctocolectomy for inflammatory bowel disease: operative technique and preliminary report.

We present the operative technique of laparoscopic proctocolectomy along with the clinical course of the first four patients to undergo this procedure. The operation was conducted through five 12-mm ports. In total laparoscopic proctocolectomy, the dissection began with the sigmoid, left colon, and rectum. The gastrocolic ligament was opened at the level of the midtransverse colon and dissected along with the transverse mesocolon toward the splenic flexure. The attachments and vessels of the right side of the gastrocolic ligament and the right colon were taken last. This sequence was followed because gradual mobilization of the colon displaced all structures in the middle of the abdomen and obscured vision. The specimen was extracted through the anus. In laparoscopy-assisted proctocolectomy, it was necessary to incise only the white line of Toldt of the ascending and descending colon, mobilize the hepatic and splenic flexures, and ligate the vessels of the gastrocolic ligament. Then the vessels of the mesentery were ligated near the bowel wall through a 6.5-cm midline subumbilical incision from which the abdominal colon was also extracted. The rectum was then completely dissected and sectioned at 10-15 cm from the anus, everted, and resected at the dentate line. Mean operative time was 7 h, 18 min, and average blood loss was 493 ml. One patient had urinary retention. Return to liquid diet took a mean of 4 days. Average postoperative stay, which depended on full return of bladder function and teaching of stoma care, was 10 days.