Page 141 - Read Online

Page 6 of 13 Ambe et al. Mini-invasive Surg 2018;2:37 I http://dx.doi.org/10.20517/2574-1225.2018.45

Figure 1. Virtual ileostomy with an exteriorized blue vassel loop following ileal pouch anal anastomosis for familial adenomatous
polyposis

Surgical management of individuals with FAP (and aFAP) should preferably be done via minimally in-
vasive access. Laparoscopic colectomy and proctocolectomy now represent standard procedures for FAP
[41]
patients. An increasing number of FAP patients are developing desmoid tumors . These fibrous tumors
are considered to be triggered by trauma, including surgical trauma. Thus reducing surgical trauma via
laparoscopic access should be a primary goal in these patients. This is also true with regard to the creation
of a diverting ileostomy during IPAA. Ileostomy creation and eventually reversal contribute to significant
surgical trauma with an increased risk of desmoid tumor. We routinely use a virtual ileostomy (ghost il-
[42]
eostomy) [Figure 1] during IPAA for FAP instead of a diverting ileostomy .

A majority of patients undergoing prophylactic proctocolectomy with FAP have no evidence of cancer.
Therefore, oncologic dissection must not be performed in these patients. However, we prefer central dis-
section of the mesentery for three reasons: first central dissection with CME is standard for oncologic
segmental colectomy. We therefore have expertise in this dissection, which is time-sparing with less vessel
ligations required. Second, there is a possibility that cancer might be found in the surgical specimen for
which oncologic resection would have been indicated. Thus a preemptive oncologic resection is sensible.
Third, the mesenteric remnant is a predisposing site for the development of desmoid tumors [Figure 2].
In this light, pelvic dissection should be performed in accordance with TME because desmoid tumors in
the remaining rectal mesentery may later impair pouch functionality. These surgical aspects are of utmost
importance because desmoid tumors comprise the second most common cause of death after cancer in pa-
tients with FAP and are the most relevant factor deteriorating the quality of life in FAP patients.

Patients undergong (prophylactic) restorative proctocolectomy with IPAA for FAP are usually young and
active. Therefore, quality of life is a central outcome measure in these patients. Key parameters in this re-
gard are the number of bowel movements and fecal continence. The continent function depends mainly
on the stool consistency, but also on the intactness of both the sphincter apparatus and the pelvic nerves.
The identification and preservation of these nerves could be difficult via the top - bottom dissection dur-
ing laparoscopic surgery. TaTME is now an established method in the management of mid and low rectal
[43]
cancer . This technique is a further modification of transanal minimally invasive techniques and enables
a bottom - top dissection with improved visualization of the pelvic nerves and a rendezvous-approach.
[44]
TaTME now represents our standard procedure for pelvic dissection during proctocolectomy .

The anastomosis technique for IPAA remains an issue of controversial debate. The most common anasto-
mosis techniques include the double purse - string with single stapling, double stapling and the hand-sewn
anastomosis. The double stapling technique is easy to perform. However, stapler intersection might pre-