OPERATIONS: Laparotomy lysis of adhesion extensive (type 3 and 4),
abdominoperitoneal resection of J-pouch; repair ileal pouch anal
anastomotic vaginal fistula; neo-ileal J-pouch; redo ileal pouch anal
anastomosis with completion proctectomy; and mucosectomy; loop
ileostomy; drain bilateral ovarian cysts; omental pedicle graft to
pelvis; repair enterotomy; and repair umbilical hernia.
ANESTHESIA: General.
PREOPERATIVE DIAGNOSES: Ilial pouch anal anastomotic vaginal fistula
status proctocolectomy and J-pouch ulcerative colitis status post
pouchitis.
OTHER DIAGNOSES: Bilateral ovarian cysts and umbilical hernia.
OPERATIVE PROCEDURE AND FINDINGS: The patient had been followed for the
chronic pouchitis by Dr. Shen and myself, and she was found to have a
pouch vaginal fistula. She had been diagnosed with ulcerative colitis in
June 2002. She underwent proctocolectomy with ileal pouch anal
anastomosis and loop ileostomy on September 19, 2003, at Jefferson
University Medical Center by Dr. Gerald Eisenberg. The loop ileostomy
was closed on February 6, 2004. She stated that approximately 2 to 3
months after ileostomy closure, she had noted some stool coming through
the pouch vaginal fistula, which had subsequently been diagnosed.
However, this was difficult to identify both at Jefferson and at the
Cleveland Clinic. The problem seemed to be relatively slight and mostly
she was feeling fairly well until the summer of 2005. At that time, she
had developed what appeared to be a Bartholin gland abscess. This was
treated by incision and drainage by Emergency Room doctor; however, the
fistula occurred after this and has persisted. She did complain of
fatigue, misses work occasionally. There has been no weight loss.
Convalescence is good. She had Remicade infusions. After the third
infusion she got a reaction, so this was discontinued in June 2006.
Repair of pouch vaginal fistula was performed in October 2006 after
first applying a seton. This had been previously treated in August 2005
with advancement rectal flap elsewhere, and she further had another
repair attempted using the Surgisis plug. Thus, the patient had some 3
attempted repairs of the fistula prior to coming to the Cleveland
Clinic. She had also been diagnosed of chronic pouchitis.
Surgery was advised after informed consent. With the patient under
general anesthetic and in the Yellofin stirrups, the abdomen and
perineum were prepared and draped. The rectal pouch was irrigated out
with saline solution. The vagina was prepared with Betadine solution.
Midline incision was used. On entering the peritoneal cavity an
umbilical hernia was identified, and this was trimmed and the sac
excised. Subsequently, this was repaired with double stranded #2 PDS
sutures.
On entering the peritoneal cavity, it was immediately apparent that
there were extensive adhesions and these were type 3 and type 4. The
pouch was traced out into the pelvis, but this was promptly interrupted
by very large bilateral multilocular ovarian cysts, which were glued to
the serosal surface of the small bowel. In the course of dissecting
these free, an enterotomy was made approximately at the site of the
previous ileostomy closure. This was repaired in 2 layers with 3-0
Vicryl, 3-0 Ethibond.
Minimal contamination occurred. Continued mobilization was then carried
out. Specifically, bilateral ureteric stents had been placed and the
ureters were tagged with chromic catgut loose marker on either side.
With this as a guide, we were able to mobilize and identify the superior
mesenteric artery as it coursed over the brim of the pelvis into the
feeding mesentry of the small ileal pouch. We were thus able to develop
a plane behind the superior mesenteric artery, and this was traced down
to the junction of the upper third and lower two-thirds of the sacrum.
However, it was apparent at this point that a problem existed. The pouch
was fused almost inextricably to the sacrum itself. Mobilization was
carried out carefully using scalpels, cautery, and scissors. However, it
was impossible despite hydrodissection to avoid injury to the pouch and
during the course of this mobilization down to the coccyx, multiple
enterotomies were made in the pouch itself. Anteriorly, the dissection
was not much easier. However, we were able to develop a plane down to
the posterior vagina. At this point, there was dense fibrosis around the
distal portion of the pouch at a distance of 2 to 3 cm cephalad to the
anastomosis. Ultimately, we were able to mobilize the entire pouch down
to the anorectal ring. At this point, the pouch was disconnected by
cutting cautery dissecting across the anastomosis itself. The pouch was
thus delivered into the abdominal wound proper.
Gloves and gowns were changed. Irrigation of the pouch was carried out
and the pelvis was packed. Hemostasis was considered excellent. However,
attention to the pouch revealed that this would require extensive
reconstruction to preserve the current pouch, and it was felt desirable
to use a new pouch. Accordingly, the pouch was excised, and the cut end
of the small intestine was checked and blood supply was considered
excellent. A Bainbridge clamp was placed across here.
The pelvis was packed. Attention was then directed to the perineum.
Effacement sutures x6 were used. Submucosal adrenaline was used in the
residual portion of the anorectum. Then a mucosectomy was carried out
starting at the dentate line extending cephalad to the anastomosis. A
number of staples were still present at the cephalad portion of this
including one or two that were fused to the posterior wall of the vagina
but these did not appear to have traversed the vagina. The defect was
identified ultimately in the vagina at this point. Closure with 2-0
Vicryl was then carried out on that defect.
Hemostasis was obtained. Copious irrigation of the perineum was carried
out. At this point, we attempted to identify if a pouch could be
delivered down into the pelvis. The particular arrangement of the
terminal ileum was such that an S pouch conferred no advantage to
fashioning a functioning pelvic reservoir. After extensive stepladder
incisions in the mesentry of the peritoneum overlying the small bowel
mesentry especially across where the superior mesenteric artery lay, it
was feasible in my view to be able to get a relatively tension-free
anastomosis.
Accordingly, a J-pouch was then constructed using 20-cm limbs by using
two passes of the ILA 100. The tip of the J was closed with a stapler,
TA30, and reinforced with Lembert sutures of 3-0 Vicryl.
The sutures were then placed into the cut edge of the anoderm including
a segment of internal sphincter; 8 of these were placed
circumferentially around the anus. This pouch was then delivered down
onto the perineum and Babcock clamps were used to maintain its position;
however, there was only modest tension on one lip at the end of the
procedure after the anastomosis was completed.
The small Fergusson retractor was placed in the open anastomosis and
further sutures were placed between the main caudal 8 sutures.
Having done this, the pouch was then tested out. This was done by
putting a rectal tube back into the pouch and insufflation with air
while holding the pouch under a layer of saline. No leaks were seen.
Attention was then directed back to the abdomen. Gloves and gowns were
changed. The previously marked stoma site was addressed, and a trephine
was made with a rectus-splitting incision. A loop of ileum was
identified upstream of the pouch and tagged proximally and distally.
This was cephalad to the enterotomy. This was then brought through the
ileostomy aperture over a sheath of Seprafilm and placed over a plastic
rod. A further sheath of Seprafilm was placed between the small bowel
and loops and the anterior abdominal wall; an omental pedicle graft had
first been placed down into the deep pelvis and sutured to the left deep
levators. In addition, an Atraum drain was placed in the pelvis and
brought out through a left lower quadrant stab incision parallel to the
omental pedicle graft that was fashioned and sutured into position.
The abdomen was then closed after mobilizing the fascia of the fat from
the previous surgery. Continuous double-stranded PDS was used for the
fascia closure. The skin was closed with staples. The stoma was then
matured with the proximal functional end cephalad and the nonfunctional
end caudad. The appliances then made, and the patient tolerated the
procedure well. She was re-dosed with antibiotics on two occasions
throughout the course of the operation and hemoglobin at the end of the
procedure was 9.2.
