Surgical Technique

The patient is positioned in the dorsal lithotomy position and catheterized with a urethral catheter. After creation of a pneumoperitoneum, a five-port transperitoneal laparoscopic approach is used. The bladder is distended with sterile saline solution and then mobilized anteriorly and laterally with standard laparoscopic techniques. An inverted U cystotomy is then made antero-superiorly with laparoscopic technique. The ileocecal junction and the distal 15 cm of ileum are laparoscopically identified. The distal margin of the ileal segment to be harvested is marked with a superficial electrocautery burn and then exteriorized through a 2-cm extension of the infraumbilical laparoscope port site. The pneumoperitoneum is then evacuated.

A 17-cm ileal segment proximal to the superficial electrocautery marking is harvested with conventional open techniques through the infraumbilical post site, with careful preservation of its vascular supply. Bowel-to-bowel continuity is restored in the side-to-side manner. The proximal end of the harvested ileal segment is opened with complete removal of the surgical staples. The segment is thoroughly irrigated with saline solution, and the proximal end of the bowel segment is spatulated for a distance of 3-4 cm along its antimesenteric surface. The bowel is then reintroduced into the abdominal cavity with the conduit caudal to the bowel anastomosis. The 2-cm extended infraumbilical incision is then closed and the pneumoperitoneum is re-established.

The mesenteric pedicle is first inspected carefully to prevent torsion. The spatu-lated proximal ileal end is oriented in relation to the cystotomy site. Single-layer ileovesical anastomosis with 2-0 absorbable sutures is then performed by laparoscopic free hand suturing and intracorporeal knot-tying techniques in a circumferential manner (Fig. 9). At the completion of the ileovesical anastomosis, the bladder is distended with saline solution via the urethral catheter to rule out leakage. The distal end of the ileal segment is brought to the skin level at the planned stoma site of the right 10-mm port site and a loop stoma or end stoma is created with open techniques. One suction drain is placed through the left 5 mm port site, with the rest of the port sites closed following evacuation of the pneumoperitoneum.

Isolation and reanastomosis of the exteriorized bowel through a 2-cm extension of an existing port site has been considered as an acceptable component of laparoscopic intestinal surgery (15). This approach provides several advantages including the ability to effectively evacuate residual fecal materials in the isolated bowel segment without significant intraperitoneal contamination, thereby minimizing abdomino-pelvic abscess formation.

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