When we began using HAL, the type of hand-port we chose was a Lap-Disc (Ethicon Endosurgery, USA;
Fig. 4). This system is made of rubber rings and a double circle which allows its rotation and closure as a diaphragm around the hand, while at the bottom, the rubber ring models its form, which is generally opened in the hypogastrium site, on the abdominal wall (7-cm incision according to Pfannenstiel).
The patient is adjusted as for a cholecystectomy with parted legs and the operator in between, and the operation begins with a Pfannenstiel incision in the hypogastric region of exactly 7 cm. After opening the cutaneous tissue and subcutaneous tissue, we proceed by liberating the fascia vertically for 7 cm, opening it according to Kustner. We prepare a temporary suture between the peritoneum and fascia on the two sides of the incision to reduce the trauma caused by the divaricators in the first phase ("open") and by the hand in the second phase ("HAL"). Exposing the operative field in a traditional way, we proceed on the right to identify and lift the cecum and to mobilise it with its appendix and the last tract of ileum (Fig. 5).
We separate the ileum and cecum with a linear stapler (GIA60), taking care to spare as much ileum as possible. We identify the right ureter and gonadic vessels and complete the mobilisation of the cecum with the section of the terminal branches directed towards it, sparing the ileo-colic artery arch. We uncover the sigmoid-rectal junction and prepare the rectum and separate it from the sigma again with the linear stapler GIA60 already used. We proceed by further mobilising the sigma by tying and sectioning the sigmoidal vessels reached through the Pfannenstiel incision.
Inserting the first 10-mm trocar on the right side,
Fig. 6. Videolaparoscopic colectomy: right hand controlling Ligasure-Atlas and left hand in the patient's abdomen through Lap Disc we place the Lap-Disc in the Pfannenstiel incision inducing pneumoperitoneum. We insert the second 10-mm trocar on the left symmetrically to the first. We introduce the video-camera which will remain on the right for the entire operation (the operation is possible with both the 0 and 30° optical camera, even if the second option offers a better view). We observe the visceral disposition and introduce the third and last trocar in the right hypochondrium near the rib arcade (Fig. 6).
Tractioning the sigmoid colon with the left hand and using a Babcock forceps through the upper trocar, we expose the colon mesentery starting the synthesis and section of the colic vessels with the instrument inserted in the left trocar. We generally use a radiofrequency instrument (Ligasure-Atlas™, Valleylab, CA, USA), particularly indicated for colic vessels; but also the last generation of ultrasound instruments (Ultracision®, Ethicon Endosurgery, OH, USA) can be used. These instruments allow a reduction in the instrument traffic which was responsible for the increased surgical time during the first years of experience with this surgery. Thus, it is possible to perform the entire operation with just one instrument.
Fig. 6. Videolaparoscopic colectomy: right hand controlling Ligasure-Atlas and left hand in the patient's abdomen through Lap Disc
Fig. 8a, b. Extraction of specimen through Lap Disc
Fig. 7a Mobilisation of left colon. b Section of gastro-colic ligament. c Section of the middle colic artery
Fig. 8a, b. Extraction of specimen through Lap Disc
The curved end of the Ligasure-Atlas also allows a gentle dissection similar to that obtainable with fingers. Mobilisation of the left flexure (Fig. 7), like in open surgery, is a delicate phase of the operation that can be carried out after separating the omentum in the colic corner either continuing the liberation facing the spleen, or from above, after separating colon from the stomach, sectioning the gastrocolic ligament. In more complex cases either approach can be used. In order to facilitate gestures on the right colon and on the hepatic flexure, we rotate the patient to the left and begin mobilising the right colon, trac-tioning the cecum to the left with the hand. After recognising the duodenum we complete the section of the right colon mesentery and hepatic flexure until we obtain the complete liberation of the colon which can be easily removed through the Lap-Disc (Fig. 8).
The operation is carried out with a hand-sewn end-to-end anastomosis between the terminal ileum and the previously sectioned rectum (IRA). Preference for a hand-sewn anastomosis, which can be comfortably performed through the Pfannanstiel incision, is dictated by the need to preserve as much ileum length as possible to be able to perform an IPAA, when necessary, with maximum guarantee of success.
If a proctocolectomy is indicated, we proceed as already described for the colectomy, except for the fact that the rectum is not initially sectioned and that the pneumoperitoneum can be maintained by removing the colon through the Lap-Disc. This also allows a traction on the rectum so that pelvic dissection is facilitated (Fig. 9); once the pelvic floor is reached, the rectum is sectioned on the plane of the elevator muscle. Rectum removal, especially in men, is conducted following an intramesenteric plane in order to minimise the risk of neurological damage, unless a TME (total mesorectal excision) is indicated by the presence of cancer. After this first proctecto-my, restorative surgery is carried out including mobilisation of the terminal ileum mesentery, preparation of the ileal pouch and of the ileo-anal anasto-
Fig. 9. Phases of rectum mobilization in laparoscopy
Fig. 10. S pouch (section design, position in the pelvis, operative view)
mosis, both protected by a loop-ileostomy. In our experience, this surgery is always performed using a traditional approach using the 7-cm Pfannenstiel incision, or enlarging it by a few centimetres, to mobilise the terminal ileum and prepare the "S" reservoir (three loop pouch) [38-40].
World literature documents the easier execution of the J pouch which can be entirely made with staplers, but in our opinion there are still good reasons to prefer a more handmade approach, with a hand-sewn S pouch that permits personal adjustments case by case, depending on the patient's characteristics. In our experience and in that of other authors , the terminal ileum sectioned on the ileo-cecal valve can reach a more distant site than the end of a J pouch. Even after mobilisation of the terminal ileum and section of the ileo-colic artery, which allows its maximum length, an S pouch does not modify the total length of the vascular arch. Moreover, the risk of needing to drop IPAA cannot be underestimated, even in expert hands, as it accounts for over 4% of the cases for different reasons  such as difficul
ties related to ileum vascularisation (Fig. 10).
Moreover, in our experience, as the mucosectomy has to be carried out from the dentate line, the "S" reservoir seems to be the most suitable. An aspect that is still being discussed, however, concerns the suitability of performing a mucosectomy and thus a hand-sewn, end-to-end, ileoanal anastomosis (for the S reservoir), removing the residual rectal mucosa (1.5-3 cm long) from the dentate line including the transitional epithelium between the anal and rectal mucosa. If a mucosectomy is not performed and stapling (often double stapling) is carried out, the entire transitional zone—at a minimum—is left: more centimetres of rectal mucosa may easily be left in relation to the thickness of the pelvic floor, the patient's sex and surgeon's skills.
The benefits of stapling include faster operating times, slightly better functional results and the possibility of avoiding a protective ileostomy. However, a 28% risk of adenomas forming in the transition zone and in the residual rectal mucosa exists, as demonstrated by Remzi et al. . In our opinion, the risk
of cancer developing is relevant as it is not always easy to monitor and treat polyps close to the dentate line and malignant transformation can also occur during endoscopic follow-up .
Also Ooi et al. , in a recent work, points out the need for careful monitoring of the transitional zone left In Situ for cancer risks, and reconsiders the suitability of mucosectomy in patients with widespread polyps on the rectal mucosa. In our experience, we have always carried out mucosectomy from the dentate line and in the second case of FAP operated on in 1985, this decision was prompted by the discovery of a stage A Dukes carcinoma in the removed mucosa section. Once mucosectomy is carried out and the reservoir is located in the pelvic space, ileoanal hand-sewn anastomosis in one layer is executed (Figs. 11,12 ).
From 1984 to 2005, we have operated on 40 cases of FAP with all the techniques in our possession, including the Kock pouch for a continent ileostomy in a patient who could not preserve the sphincters but wanted to reduce the problems related to definitive ileostomy. In 1996, we started treating FAP patients, when possible, with the videolaparoscopic techniques previously described. In this period, 9 out of 17 FAP patients were treated (2 with IRA, 7 with IPAA) with VDL or HALS, without any major complications when compared to the traditional open technique. Only two patients needed postoperative blood transfusion (one for each group) and no one in the laparoscopic group had an infection of the Pfannestiel incision. In our experience functional results such as continence, urgency, number of bowel movements and sexual functions do not differ significantly between IRA and IPAA and in patients operated with traditional or laparoscopic technique. With the HALS technique, the time needed to perform an IRA or IPAA is now quite similar to that needed in the traditional open technique; postoperative pain is normally lower and the patient can be discharged earlier. Moreover, the cost-effectiveness of laparoscopy increases with experience and patient satisfaction is greater. At the moment, the low number of patients operated on with this technique does not allow statistical evaluation of the risk of postoperative bowel occlusion and of desmoid tumour growth at the scar site. The laparoscopic experience obtained by treating IBD patients with HALS showed an absence of adherences in the second stage of the operation (proctectomy and IPAA) and this situation seems to reduce the risk of bowel occlusion. None of the nine patients treated with laparoscopy needed readmission, while 2 out of 31 patients treated traditionally were readmitted due to bowel occlusion and one needed surgery for adherences.
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