International Symposium　State-of-the-Art Management of IBD: Integrating Medical and Surgical Strategies in Clinical Practice

[IS-4] Challenges and Future Perspectives of Surgery for Ulcerative Colitis

*Koji Okabayashi^1,2, Kohei Shigeta², Kenichi Okada¹, Kazuo Koyanagi¹, Seiichiro Yamamoto¹ (1. Department of Gastrointestinal Surgery, Tokai University School of Medicine, Japan, 2. Department of Surgery, Keio University School of Medicine, Japan)

Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) is the standard surgical treatment for refractory ulcerative colitis (UC). While minimally invasive surgery (MIS) improved outcomes, challenges remain regarding abdominal wall trauma and stoma management. Previously, we evaluated various MIS approaches, including laparoscopy, hand-assisted laparoscopic surgery (HALS), and reduced port surgery with transanal total mesorectal excision (RPS+taTME), showing that tailored selection minimizes complications. Recently, we developed a unique technique: fully intracorporeal J-pouch construction with a "ghost ileostomy." The specimen is extracted transanally, and the pouch is formed completely intracorporeally to minimize additional incisions. To ensure length and perfusion, we utilize transanal transillumination of the mesentery and indocyanine green (ICG) fluorescence angiography for selective vascular division. The ghost ileostomy serves as an effective safety net, allowing us to safely omit a routine defunctioning stoma. However, achieving the standardization of this highly demanding intracorporeal approach remains the ultimate challenge, as its reproducibility currently depends on expert skills. As a future perspective, integrating robot-assisted surgery may overcome these ergonomic limitations, as its multi-joint articulation and stable instrumentation can facilitate deep pelvic dissection and intracorporeal suturing. Overcoming these technical barriers to standardize this sophisticated procedure is essential for its widespread adoption. In conclusion, this presentation discusses future perspectives in UC surgery, focusing on pathways toward standardizing next-generation intracorporeal innovations.