Name of the Case

Single Incision Laparoscopic Total Colectomy for Intestinal Neuronal Dysplasia Type B

Data

Name: F-36

Age: 36 years old

Sex: Female

Date of Birth: April 28, 1985

Address: Brgy. Bitas, Cabanatuan City

Occupation: Government Employee

Religion: Catholic

History of Illness

A 36-year-old female patient presented to our department complaining of longstanding

constipation during 20 years. She had received various treatments including some supplements
and various laxatives. However, those treatments were ineffective, her symptoms worsened
year by year. Eventually, she had taken over 70 tablets of stimulant laxatives per day.

Signs and Symptoms

 Refractory Constipation

How it is Diagnosed

It was diagnosed with refractory constipation of the medication treatment-resistance.

Colonoscopy showed melanosis in her entire colon, whereas did not reveal any mechanical
obstruction. Total colectomy with ileorectal anastomosis by single incision laparoscopic surgery
(SILS) was performed. The final pathological diagnosis was Intestinal Neuronal Dysplasia Type B
(IND-B).
Laboratory Procedures and Results

Preoperative
Clinical examination revealed soft and flat abdomen, and bowel sound was normal.
Barium-enema examination and abdominal computed tomography scan showed
elongated colon, but did not found any mechanical obstruction. Colonoscopy showed
melanosis in her entire colon, whereas did not reveal any mechanical obstruction. After
a preoperative consultation with the patient and her family, total colectomy with
ileorectal anastomosis by SILS was performed.

Postoperative
The pathological findings of the resected colon showed that the nerve bundles appeared
hypertrophic, containing increased numbers of thickened disorganized axons in the
intramuscular and submucosal nerve fascicles.

Date and Time of Admission and Discharge

Admission: July 10, 2021 at 10:45 am

Discharge: July 18, 2021 at 11:15 am

Anesthesia Taken (Type)

General Anesthesia

Ketamine was used alone as general anesthesia, and it was introduced

intravenously.

Type of Surgery (Operation Performed)

Total Colectomy with Ileorectal Anastomosis by Single Incision Laparoscopic Surgery

She was placed in the supine position, and a 3-cm “zigzag skin incision” through the
umbilicus was made. A lap protector and EZ Access (Hakko Co., Ltd., Tokyo, Japan) were placed
through the incision. Three 5-mm ports were placed in EZ access mounted on the lap protector,
and pneumoperitoneum was obtained. Almost all the procedures were performed with usual
laparoscopic instruments and the operative procedures were much the same as in usual
laparoscopic colectomy. To obtain better exposure of the operative field, we used
percutaneous traction of vessel pedicles by suture thread needle in the medial approach. At
first, we started from the mobilization of the left side colon by medial approach. Followed by
opening omental bursa, it took down the splenic flexure, and finished the full mobilization of
the left side colon. Subsequently, it was working on the mobilization of the right side colon
using a medial approach. After the division and ligation of the ileocolic vessels, blunt dissection
was performed toward the hepatic flexure in upper layer of subperitoneal fascia and it finished
the mobilization of hepatic flexure by dissection of lateral attachment. Finally, the specimen
was extracted through the umbilical port, and colon resection between ileum end and recto-
sigmoid colon was extracorporeally achieved. Functional end to end ileorectal anastomosis was
performed with staplers. The operation time was 187 min and intraoperative blood loss was
only 10 ml.

Preoperative and Postoperative Drugs (Drug Study)

Preoperative drugs

 Stop taking certain medications. Certain medications can increase your risk of

complications during surgery, so your doctor may ask that you stop taking those
medications before your surgery.
 Drink a solution that clears your bowels. Your doctor may prescribe a laxative
solution that you mix with water at home. You drink the solution over several hours,
following the directions. The solution causes diarrhea to help empty your colon.
Your doctor may also recommend enemas.
 Cefazolin is an antibiotic. It was administered before performing the surgery to help
reduce the risk of postoperative infections.

Postoperative drugs

 Morphine
 These can be transitioned to oral pain medications like acetaminophen

History of the Case

A 36 year-old woman suffering from longstanding chronic constipation and who was
diagnosed with severe constipation in more than 20 years. Although she began to take a large
amount of stimulant laxatives, such as “senna” and “bisacodyl”, constipation symptoms did not
improve, she was admitted to our hospital. It was diagnosed with refractory constipation of the
medication treatment-resistance, total colectomy with ileorectal anastomosis by single incision
laparoscopic surgery (SILS) was performed. The final pathological diagnosis was IND-B.
Health Teachings

Nutrition
 You may not be able to eat solid foods at first. You might receive liquid nutrition
through a vein, often in your arm, and then transition to drinking clear liquids. As
your intestines recover, you can eventually add solid foods.

Activity
 Most normal activities may be able to resume in 1 or 2 weeks. These activities
include showering, driving, walking up stairs, and engaging in sexual activity.

Wound Care
 Always wash hand before and after touching the incision site.
 Do not soak in bathtub until stitches or staples are removed.
 Avoid wearing tight clothes. It would make it harder for them to heal.

Pain Control
 Medicine will be needed after the operation, and the doctor will advise how
much you should take.

Course of Disease

She had suffered from longstanding, refractory constipation during over 20 years. She
was diagnosed with refractory constipation of the medication treatment-resistance, total
colectomy with ileorectal anastomosis by single incision laparoscopic surgery (SILS) was
performed. The final pathological diagnosis was IND-B. The postoperative course was
uneventful, and she was discharged on postoperative day 8. Her operative scar was small and
very cosmetic. She has remained asymptomatic with normal bowel motility during a 2-year
follow-up.

References

Crader MF, Varacallo M. Preoperative Antibiotic Prophylaxis. [Updated 2021 Jul 18]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK442032/
Masuda, T., Nonaka, T., Adachi, T., Hisanaga, M., Nagayoshi, S., Tokunaga, T., Taniguchi, K.,
Kurohama, H., Ito, M., & Fujioka, H. (2017). A case of single incision laparoscopic total
colectomy for intestinal neuronal dysplasia type B. International journal of surgery case
reports, 38, 122–127. https://doi.org/10.1016/j.ijscr.2017.07.026