Ileoanal J Pouch Construction

Ileal pouch-anal anastomosis (IPAA) is the preferred operation to restore gastrointestinal continuity following a total proctocolectomy as an alternative to an end ileostomy. J pouch is the most common IPAA however remains a technically challenging operation. One of the key requirements is acquiring adequate reach of the small bowel down to the pelvis to create a tension free ileoanal anastomosis as a wide variety of complications have been documented when an IPAA anastomosis is made under tension.

In our video we describe the steps necessary to perform an IPAA and several operative tips to overcome the common challenges . The case we describe is of a thirty-five-year-old patient that presents for an elective open J pouch construction and ileoanal anastomosis following a previous total proctocolectomy and end ileostomy for ulcerative colitis six years prior. The operation shown in the video is performed by an open approach however we believe the techniques described apply to a laparoscopic and robotic approach as well.

After taking down the existing stoma and entering the abdomen, the first step to performing an IPAA is adequate adhesiolysis of small bowel beginning from the level of the duodenum down to the distal end of the ileum.  This is an important step to ensure reach of the pouch down to the pelvis to create a tension free anastomosis. Next, we perform mesenteric relaxing incisions as a technique to achieve further reach. We then demonstrate a method to assess for reach using the inferior border of the pubic symphysis as a landmark. This method is especially useful when considering a minimally invasive approach with exteriorisation of the bowel or when there is limited access due to a narrow pelvis. Once sufficient length is achieved the J pouch can be constructed. We demonstrate our technique to create a J pouch by utilising multiple firings of a linear cutting stapler. Next, we outline the steps to orientate the pouch with the mesentery located anteriorly and demonstrate the benefit of our lengthening techniques. Finally, we utilise a circular stapler to create the ileo-anal anastomosis after confirmation of orientation.