Reversal of a Diversion Loop Ileostomy in a Patient with a Prior Gracilis Transposition Flap for Rectovaginal Fistula Due to Crohn’s Disease

CHAPTER 1

I'm Dr. Steve Wexner. I'm the Chair of the Department of Colorectal Surgery, and the Director of the Ellen Leifer Shulman and Steven Shulman Digestive Disease Center in Cleveland Clinic, Florida, in Weston. And with me is one of my fellows, Dr. Zoe Garoufalia. I'm Zoe Garoufalia, one of the clinical fellows in Cleveland Clinic Florida and I'm also general surgeon from Athens, Greece. So, we're gonna chat first about the patient on whom we're performing an ileostomy closure, and Zoe, why don't you tell us a little bit about this patient? So, this patient is a 25-year-old female, with a history of Crohn's disease that unfortunately got complicated with a rectovaginal fistula. In the beginning with tried to treat it with the endorectal advancement flap that unfortunately failed two months later, so, following our step-up approach, we opted treating it with left-sided gracilis transposition flap and before doing that we always divert the patient. So, we performed a diverting loop ileostomy before the gracilis, we performed the gracilis flap, everything went as planned. Her fistula healed as shown by her exams, her gastrografin enema, her MRI, and our clinical exam. So, we proceeded to closing her ileostomy. And prior to ileostomy closure, we always obtain several things in every patient, in the case of the gracilis, not only a water-soluble contrast enema and a vaginogram, vaginoscopy, but an examination under anesthesia because the flaps that accompany these gracilis muscles are very low, almost at the anal verge, certainly the dentate line or below and the gastrografin or water-soluble contrast enema will sometimes miss a fistula there. So, an MRI can be a good adjunct in these cases, but an examination under anesthesia is the ultimate gold standard. So, the patient had all of those things done, MRI, vaginogram, water-soluble contrast enema, vaginoscopy, flexible sigmoidoscopy, exam under anesthesia, fistula's healed. The ileostomy closure, you're gonna see some technical details and the one that I'd highlight that's different, instead of putting a TA type stapler over the common enterotomy, I remove the mesenteric corners with a bipolar energy device, which allows a rectangular rather than rhomboid closure, and allows me to use a reload on a GIA 100 stapler rather than having to take a new stapler of a different kind and a TA to close the common enterotomy, and it allows for having only two cross points at the corners rather than the typical rhomboid configuration where it's four cross points, corner, staples crossing, staples crossing, corner. This way it's just the two corners and, so you'll notice that one difference. Everything else is probably like other ileostomy closures you've seen but this one detail will definitely be different and my logic is to have less cross points. So, first we mobilize our ileostomy making sure we're getting down to the fascia avoiding any possible seromyotomies. Once the two limbs, the efferent and afferent are fully mobilized, in case we have any worries that there are seromyotomies, we can do this wonderful trick that Dr. Wexner has taught us. We partially occlude both limbs and we inject betadine solution to make sure that there is no extravasation, and once this is done then we trim the end of the ileostomy, of the two limbs, and after dissecting the mesentery, we perform our stapled side-to-side anastomosis, making sure it's hemostatic and if not, we're placing some PDS sutures, and then closing the apical line with the GIA handheld, that Dr. Wexner mentioned, to avoid the Rhomboid closure. And again, testing for hemostasis and then placing the new anastomosis inside the abdomen and closing with interrupted PDS sutures, the fascia. And, we always leave the wound open because there is a high chance of SSI in these types of wounds. The betadine test is very helpful that you can occlude the bowels and squeeze betadine under pressure so the bowel blows up like a balloon and if there's any seremotomies, they're highlighted, you see the color change at those areas and can either elect to ressect or suture imbricate those areas at your pleasure. This patient like many patients of a high BMI has a parastomal hernia around her ileostomy and so, you may get to see a parastomal hernia repair as part of it, but that's fairly common and again in increased BMI patient's it's more common. The hundred stapler is an interesting one and we recently for the second time published our results on using a GIA 100 as opposed to 60 or 80, and there are people in the department who use 60s and 80s, and we found indeed superior outcomes with the 100, in part a more rapid return of bowel function. About a one-day shorter period of illeus and some superior safety outcomes, using a longer stapler. So, that 100 also allows for closure of the common enterotomy. I'm not sure you could do it with a 60, perhaps with an 80, and having a 100 allows us to do that apical closure too. And one other thing we do is we put a few sutures, usually three sutures between the afferent and efferent limbs, 3-0 PDS sutures at the point where the staple line starts, not at the common enterotomy, just to help take the pressure off of those few staples. And, if I may add just one other pearl of wisdom from Dr. Wexner, that is really, really usable, especially in young surgeons, don't be stingy on the, the fascia incision. Every time that you get some issues going back the anastomosis in, just make it bigger, either for dissecting the two loops when you are trying to do your anastomosis, perform your anastomosis, or when trying to place the anastomosis back into the abdomen. Otherwise you get venous congestion and there are higher rates of leak afterwards. Yeah, that's a very good point. Particularly in somebody who's a high BMI, it may seem like it's a big aperture, but that's just the skin, and the fascial aperture may not be that big, and so you perhaps need to make it bigger to relieve that venous congestion. That's an excellent point. Another trick you can sometimes do in an ileostomy closure is put a wound protector in, one of the stretchy wound protectors to help the bowel pop back in as necessary, and sometimes that's even useful during dissection.

CHAPTER 2

Starting. Now, leave that off. Can you hook up the smoke evac? Just since we're using it, may as well. The regular. Let's switch. There's a speck on that edge there. Just a DeBakey. Uh, right on your retractor, please. So, hold down on that. Metz, please. Now, the DeBakey, please. You can get... Hm? You can get around that. Digging down in the hole. That's the sac. This is omentum. Omentum. You can take it off with a Bovie, on my finger. You have a - yeah. Is this part of that meso hole? Let me see. Can I get some Adsons again? Pull up on the fascial edge, and I'll expose for you. We'll need a LigaSure, do you have LigaSure? We do, we do. Okay. You can take this just with, uh, all this. That's part of that meso or not? A little ways, just that edge, so... Now there are you stuck? No, another... Watch the back side of the fascia, the muscle in there. Yeah. Do you have something... Like an Army-Navy times two? No, like a Richardson? All right. All right. Now there is some adhesion inside. I can see it. Yeah, if you can see it, get it. Let me just feel first. This is all tethered down here. That's the meso, though. This, this is stuck to fascia, still. The problem is, this is all the way back here, the fascia is here, huh? This is efferent. Okay, let's do this. Okay, let's come around here. Okay. Yeah, like under here. Yeah, wow. And then this is going... That's gonna be TI, see? There's ligament of Treves? Yeah. So, let's try and expose this without tearing it. Okay, hold this like this. Give me the Bovie extender, please. Quite a hernia here. Okay, so, yeah. So, what we're doing here is trying to lyse these adhesions to the hernia sac, right by the end of the terminal ileum. We're trying to gently release here. See, this is the wrong side of the fascia. It's like one more loop there. You know, maybe we got it. No, a little bit more there. Okay, give me another retractor, please. Then suck in there please. Okay. Here. Okay. Wow, huh? This is another loop of something, or this is... No, there's more stuck. Okay. Take maybe this side here. Huh? Well, this is all the way down on fascia there. Stay out as close as, yeah it's right there, see the edge? Go right on fascia. All the way down there, yep. There's the edge. Suck real good. There's the edge. Hold on. Woo, vicious adhesions. Okay, free to the TI. Huh? Said, free to the TI. Oh, free to the TI but we're gonna have to fill with betadine and see what all this looks like, 'cause this is just vicious adhesions. From her hernia, if we had to we could use the end but I'd like, be nice if we didn't have to resect it. Take, we'll see, if we need to take that off, we will. If not, if everything looks good... This we'll certainly resect. Open? Unless you can show us how to use it in the box. Yeah, LigaSure. Then we want the betadine and a bulb syringe. Two blue towels. Wow, look at this.

CHAPTER 3

Okay, betadine, please. Okay, guys, squirt it under pressure here. This is something good to show on the camera, how we check for seromyotomies, the efferent limb, afferent we know we're resecting. No, this, this yeah, but squeeze it so it doesn't... So, we put betadine under pressure and we very carefully look to see if there's any areas that are thin that would need to be either resected or suture re-enforced, lab pad, please. Uh uh, right there. Right there, see how this shows a little bit? So, that certainly needs, our choices are to resect all of this and anastomose here, if there's multiple areas that's what we're gonna do. This is okay. Well, there's another one here, there's a small one right there. Then the small, that's actually maybe a blood clot, well, no. No, it's fine. Yeah, the problem is, this is all fine actually. But there's this, where does this go to, there, and here, so, the choice is, we either resect all of that and we anastomose to something that's totally blind, or we try and save this length here. Well, then we save a lot of her small bowel length. She has Crohn's. And she has Crohn's disease so... This is still stuck too. Get your Bovie and come in here. Just release this a little. Let's see, this is stuck, so, even, it's actually all good except for that. So, we're talking about 10... Like 20, that's a lot. 20, 30, yeah, 3-0 PDS. Suctioning all of that? Yeah, this almost mesant... The problem with this one though, it's really on the mesenteric margin. You know, to duck this in. Yep. Yeah, 3-0 PDS. Here let me, right in the middle. Here, so, imbricate. That's better. Yep. We'll do one on each side. So, let's tag the middle one. Tag, please. Okay. So, with her history of Crohn's we'd rather not take another 30 centimeters of her terminal ileum if we can avoid it. Can I get the DeBakey please? It's almost already imbricated. Okay, let me have a towel for my head light please. It got knocked sideways here. Thank you. Oh, she's up here, we're on our way? Good. We can cut, I think. Maybe do one, get another stitch please. One in the front? Yeah, I'm gonna do one straight across. It's already imbricated but now I just do one sort of straight across, without imbricating any more, and tie that one. Cut. Okay, the other one was, let's have the betadine again. I think it's right there, but let's reinsulate. Betadine, go ahead, redo it, let's see. Go ahead, you hold. So, firstly is this anything here? This, no, this is just on top. I'm just looking if this is anything underneath here. Now, that I think is just on top. I'm just looking under it, if we wanna... That looks reasonable. This is... Right there, do we think that's anything? Or it's just stuff on top. I think it's on top. That's the other spot. 3-0 PDS, please. It may be a hematoma. Yeah, it's very... But, I still think I'd imbricate it. 3-0 PDS today for the station. Let's just imbricate that anyway, just to be safe. I think it's a hematoma on the top. The more I look at it, yeah, I think it's actually... It's not actually in the bowel. It's in the adhesion, right? Okay, so it's nothing in the bowel. So, let's, one more round of betadine. Needle back. Betadine again, please. Can you raise the table a little bit, please? Sure, table coming up. This now looks fine. Okay. Yeah, I think that's fine. That's, now, it looks a little more like... Adhesion stretched out on the... Yeah, but it's really not, everything else is perfect. Except this little area here. The only question is that one. I don't wanna narrow it too much, either. Huh? Can just put one in. Yeah, 3-0 PDS. I don't think it's much. I think it's like over in, I think it's an adhesion. Good ahead and tie it. Right at the same spot where it was... And then one last round of betadine, just to see it all goes through nicely. Betadine again, please. Just to demonstrate that it's patent and a good lumen. Go ahead, fill it up. Yeah, it goes right through. So, the betadine goes right through there, good lumen, okay, fine.

CHAPTER 4

Turn the tips the other way. I just always prefer to go towards rather than away from... Twice, please. Okay, the other side, I don't think we did that yet. This little window here. GIA 100 next, please.

CHAPTER 5

Okay, so we divide each end of the bowel. Okay, fire. Allis, please, I got it, nevermind, okay. What's next? Reload, reload. There's the mesentery stuck, that we got into. Okay. Go ahead and try it. It's okay, we're gonna open it anyway. Ileostomy.

CHAPTER 6

Open the corners. Make it a little bigger so we can, yeah. Use cut on the corner. Just the tip, very tip, works best. Same. Buzz this, please. Okay. I'd probably do the other way, 'cause this narrow, this will be a more narrow caliber because it's efferent, and then the other one's gonna be wider, 'cause it's afferent. Okay. We gotta watch the tips very carefully, that you don't poke the tips through. So, come on in a little more. So, keeping the mesenteries opposite and the tips careful to not perforate, and you can close. Yep. And once it's closed, then we can fire. And always hold the neck of the stapler so it doesn't accidentally slip anywhere. Then we're gonna... Allis. Then, we're going to take off the corners so that we have a rectangular, rather than rhomboid closure of the corners. So, we're gonna go to here. Take the liga maybe, please. Slide down a little, yep. Okay, so this way we have a square, rather than a rhomboid closure. Or rectangular. Possibly need a 3-0, see where the... Seems fairly dry, but we'll look. Allis. Allis, please. 3-0 PDS. Yep, there it's bleeding. Okay, 3-0 PDS, let's go, start sewing. Adjust the staple line. Hold this one. Just the staple line. So, this is for reinforcing hemostasis on the staple line. Okay, cut. Another one just past it. I think there was one going back the other way, too. Just right at the end. It's gonna be removed but still, just for the sake of hemostasis, I would take it. Keep 'em coming. Have one loaded and ready to go, okay? Instead of waiting every time. There, another Allis, please. So, sometimes what helps here is you can turn the entire anastomosis inside out to look right down at the very bottom, I'm gonna kinda, another Allis, try and demonstrate that. And this is sometimes helpful in like a J-pouch operation. On the staple line here? Yeah, we can open the staple line a little more too. That's gonna be closed anyway. Another Allis. Oh there, you can see, now you can see, there's the very apex of the staple line. So, that's often where it's bleeding, right at the very, very end of the staple line. It's right next to the spleen, leaving a little hematoma there, so, we're gonna put a few stitches there. Then, once he ties, I'm gonna take this Allis, which is on the anti-mesenteric wall off, because I'd rather not leave it on any longer than needed. We'll put a tag here in place of this Allis. Okay. Okay. Okay, so, I'm gonna take this one off and this becomes the apex. And, now we can look here and see, I think one here Dave, and one, a couple in here, 'cause there's a little hematoma, see right there? So, just along there, starting here. Yep. We'll tag this too, okay? Okay, I think, one by the hematoma too, just to be, see it right here. Yeah, even though it's not bleeding now, just to be sure. We can take this one off. Here you go. Take these back, please. We'll use them again in a few minutes. We'll have another tag. Perfect. That's perfect. Cut. Okay, keep going. Needle right here.

CHAPTER 7

Okay, now let's offset. I need a few more Allises now. So, you wanna offset the staple lines when you close. So, you can go either this way a little bit, or this way, so the two staple lines offset. I think this way may be marginally better today. If those staple lines are offset, they're not exactly opposite each other. Allis, Allis, another Allis next. Another one? One more. Stapler, please. Stapler. You're gonna come right here. You wanna make sure it's flat, okay, in the middle, yep. And then we're gonna look at the mesentery, I might try this one down slightly, hold on, hold on, on this side, open. Let's slide, okay close. I wanna, go ahead close, I wanna show him, that the mesentery is right to the edge. It's well vascularized, right? So, you can see here, good mesentery right to the edge. Cut. I'd rather it bleed than be ischemic. Okay, let's change these green towels. What's going on? Okay, so here, grab this so you don't get a hematoma. Exactly, figure of eight out here is fine, when it's mesentery, but anything on the staple line just those simple staple line sutures. Don't make it too big. Like here, I'll follow you. Take the, take the pickups off, just so we can see exactly the spot bleeding. Yeah, just take, 'cause you don't want too much. Okay. Can we have a clean lap, please? These are dirty. Not, no, just the staple line, yep. May need one next to that one. This other side doesn't look bad. There' s a little bit more touch up to do there, and then we do a couple of stitches here to support the staple line. Yep. Another stitch ready. Oh no, there's bleeding out there. Give him another stitch, please. Okay. Do six knots, I've been counting five in the last couple, I didn't say anything, but... Yeah, I've been just putting five here, 'cause it's not on tension. I think it just unravels. I think it's a little further over, here. Yeah, like there. I think it looks pretty good. Okay, do the cross-stitches and then put it back in and close. Let's see, so, three of them, yep. You guys change gloves too. Another stitch ready. Stitch. Okay. Two more, just go straight across, you don't have to imbricate anymore.

CHAPTER 8

Okay, so that all looks good. Looks dry, so, I think we can put it back where it belongs. It's not even actually in the fascia yet, you know that? Now it's in.

CHAPTER 9

Yeah, the fascial opening isn't actually that small, it's just that the hernia was very large. Curious stonewall looks like Crohn's. Peristomal ulceration. Or peristomal skin. Yeah, well I need a bigger Richardson in. Two Richardson's, please. I think it's actually up here. Uh huh. Yeah, fascia right there. Yeah. Dave can see the fascia? Yeah. You need to take little bit, this is muscle, I know, but you need to clean it. Yeah. Start on my side. Sure, I'll start over there. Suction retraction's working the best. Now take that, now your muscles, get your fascia. Can you hold this? Your fascia's actually retracted there. Yeah. There's a vein right in here. Have yo decided if you're gonna take the hernia sac, or no? We will once, yeah we will, once we clear off the fascia. We will take the hernia sac. Uh huh. Yeah, that's fascia, that's fascia. I don't have it properly. No, we're gonna, we're gonna take it out. We're gonna close then take it out. Yeah, we'll take more. So, right there. Yeah, come around the corner. Yeah, I see it. Yeah, that's fascia there. That's fine. All right, we're good. All right, we'll take the number 1 PDS. Can we have a clean lap, please? This is dirty. Like with the cross on the bottom, or cross on the top? Like, one, one, one, one. Okay, so... Like the real one. Our first count is correct. Thank you. I'm gonna come on this side of your Kocher. That's fine. Maybe I should just hold it. No, it should go to this one. Another suture, please.

CHAPTER 10

Not as much as I thought it was gonna be. I thought it was more, you know, hernia sac. Don't really have to thin this, but...

CHAPTER 11

So it don't bleed is what I meant. Do you have the Vicryl? Yes, 0 Vicryl... He will like to have an Adson. Thank you. All right. You don't want this? Doesn't matter.