C H A P T E R 63 • Ileoanal Anastomosis (Straight and J Pouch) |
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The pedicle is thinned, clamped, divided, and ligated in standard fashion. Identification of the left ureter should be made before this to ensure it has not been drawn up into the pedicle.
The posterior avascular mesorectal plane is entered, and sharp dissection is carried down to the levator muscles. Care is taken to ensure that the superior and inferior hypogastric nerve plexus running deep to this fascial plane is not damaged (see comments in Pearls and Pitfalls section).
Lateral dissection is then carried down in the appropriate avascular plane. Care is taken during division of the lateral rectal stalks. The pelvic plexus named nervi erigentes—affecting erectile function—as well as the middle rectal artery, are in close proximity to these stalks.
Anterior dissection is carried between the anterior avascular plane of Denonvillier and the reproductive structures. This is done down to the levator ani muscles.
The decision to staple or hand sew the ileal pouch anastomosis is determined by the clinical scenario. For example, patients with ulcerative colitis who do not have high-grade dysplasia may have a stapled anastomosis with mucosal surveillance on a regular basis. Patients at high risk for developing malignancy (presence of cancer or high-grade dysplasia) should have mucosectomy and hand-sewn ileal anal anastomosis.
A stapled anastomosis may be placed as low to the dentate line as anatomically possible (Figure 63-2). The posterior mesorectum tapers distally, so there should not be excess vascular tissue posteriorly, once the appropriate level of dissection has been reached.
Division below the level 
of the levator muscles
7 2 0 S E C T I O N I X • C O L O N
The specimen is detached from the proximal small bowel using a 75-mm linear stapler
(Figure 63-3).
Terminal ileum
Cecum
FIGURE 63–3
C H A P T E R 63 • Ileoanal Anastomosis (Straight and J Pouch) |
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Creation of the Ileal Pouch
Attention to the method of pedicle ligation of the ileocolic artery is of paramount importance when performing proctocolectomy with the possibility of ileal pouch creation. The ileocolic artery should be preserved through its entire distance, taking care to hug the mesenteric border of the cecum and distal terminal ileum before division of the bowel.
Adequate length of the mesentery will dictate reach to the pelvis. A good preliminary length is 1 to 2 cm distal to the pubic symphysis when measuring the apex of the pouch. Inadequate length may be regained by scoring the peritoneum or by distal ligation of the superior mesenteric artery (SMA), provided adequate collateral flow exists through the ileal branch
(Figures 63-4 and 63-5).
FIGURE 63–4
7 2 2 S E C T I O N I X • C O L O N
The apex of the pedicle is identified, and the pouch is measured so that it is approximately 15 to 20 cm from the apex (Figure 63-6).
The apex of the pouch is entered using Bovie electocautery (Figure 63-7).
Apex of ileocolic artery and pouch
Terminal ileum
FIGURE 63–6
Enterotomy
Terminal ileum
C H A P T E R 63 • Ileoanal Anastomosis (Straight and J Pouch) |
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The mesentery is positioned anterior to the pouch, because this is the shortest distance to the pelvis with the least amount of tension on the pedicle.
A 75-mm linear blue-load stapler is sequentially used to fire between the two limbs at the antimesenteric border, thus creating the pouch (Figures 63-8 and 63-9).
Placement of linear 75-mm stapler
Firing of second 75-mm linear stapler to
create common wall
7 2 4 S E C T I O N I X • C O L O N
Hand-Sewn Anastomosis
The patient is positioned from low to high lithotomy (Figure 63-10). The perineal operator places a Lone Star retractor in the anal canal. The dentate line is drawn down to the anal verge by sequential placement of retractor hooks (Figure 63-11). A Parks anal retractor may be placed to improve visualization of the anal canal. Mucosectomy is initiated first by infiltrating 10 to 20 mL of 0.25% bupivacaine (Marcaine) with 1:200,000 epinephrine circumferentially, raising the mucosa off the longitudinal muscle. The mucosa is circumferentially incised using electrocautery or sharp dissection. Metzenbaum scissors are used to lift the mucosa off the muscle proximally. Once the mucosa falls back circumferentially, a full-thickness incision is made laterally and carried circumferentially around the distal rectum. Once the specimen is free, the ileal pouch is prepared for anastomosis.
C H A P T E R 63 • Ileoanal Anastomosis (Straight and J Pouch) |
725 |
High lithotomy position
FIGURE 63–10
Hooks placed at dentate line
Lone Star retractor
Exposure of dentate line
7 2 6 S E C T I O N I X • C O L O N
A full-thickness stitch using a long 2-0 Vicryl suture is taken at the antimesenteric edge of the pouch opening (posterior) and passed to the perineal operator through the anal canal (Figure 63-12). Using the same suture, a full-thickness stitch is taken through the dentate line posteriorly. This process is repeated for both lateral sides, and finally the anterior side. The pouch is cinched down into the pelvis, and each suture is tied down (Figure 63-13). Circumferential sutures are placed between each stitch in full-thickness fashion, taking care to incorporate an edge of pouch with the dentate line. The anastomosis and mesentery should be checked to ensure both are free from tension and there are no twists.
The Lone Star retractor is removed, and the dentate is allowed to retract back into the anal canal. Proctoscopy is performed, and the anastomosis is checked for air leaks by insufflating while the proximal small bowel is clamped under saline.
C H A P T E R 63 • Ileoanal Anastomosis (Straight and J Pouch) |
727 |
2.0 Vicryl suture placed full thickness through apical opening of the pouch
FIGURE 63–12
Pouch drawn |
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Anastomosis |
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completed |
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down to pelvis |
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A 
B
2.0 Vicryl sutures passed through anal canal
7 2 8 S E C T I O N I X • C O L O N
Stapled Anastomosis
A purse-string suture using 2-0 Prolene on an SH needle is taken circumferentially around the proximal end of the bowel (Figures 63-14 and 63-15). A 29-mm circular intraluminal stapler (ILS) is opened, and the anvil is placed in the lumen of the pouch, cinching the purse-string down.
The perineal operator places the circular stapler into the rectum and is directed to the stapled end of the bowel (Figure 63-16). The main rod is deployed so that it exits either above or below the staple line. The main rod and anvil are attached. The mesentery is checked for twists and for undue tension. The circular stapler is tightened and fired. The resulting rings are inspected for completion.
A leak test is performed by introducing air into the pouch while occluding the proximal bowel. The anastomosis is submerged in saline and placed under intraluminal air tension. Presence of bubbles suggests an incomplete staple line and should be addressed accordingly.
FIGURE 63–14 |
FIGURE 63–15 |
