IAPP By Department of Surgery PDU Medical College


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This presentation is a contribution from Dr. Jatin Bhatt, Professor & HOD, Department of Surgery, PDU Medical College, Rajkot.

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IAPP By Department of Surgery PDU Medical College

  1. 1. Ileo-Anal Pouch Procedure (IPAA) <ul><li>Dr. Jatin G. Bhatt (M.S.) </li></ul><ul><li>Professor & Head </li></ul><ul><li>Dr. Yogesh K. Raichura (M.S.) </li></ul><ul><li>Dr. Ajay M. Rajyaguru (M.S.) </li></ul><ul><li>Dr. G. N. Vaghasiya (M.S.) </li></ul><ul><li>Asstt. Professor </li></ul><ul><li>Department of Surgery </li></ul><ul><li>P.D.U. Medical College </li></ul><ul><li>Rajkot. </li></ul>
  2. 2. IPAA: Indications <ul><li>Ulcerative Colitis </li></ul><ul><li>Familial Adenomatous Polyposis Coli </li></ul>
  3. 3. IPAA: Procedure <ul><li>Removal of diseased caecum, colon & rectum </li></ul><ul><li>Ileal pouch: reservoir & storage of feces </li></ul><ul><li>Ileo-anal anastomosis: continence </li></ul><ul><li>Temporary Diverting Ileostomy/sos </li></ul>
  4. 4. IPAA: Preoperative Counseling <ul><li>Functional results are not perfect </li></ul><ul><li>Pt. selected properly : physically & mentally </li></ul><ul><li>Contraindications: Crohn’s disease </li></ul><ul><li>Malignancy Overweight males Fulminating colitis </li></ul><ul><li>Poor anal continence </li></ul>
  5. 5. IPAA: Preoperative Counseling If the patient is fit, understands the less than perfect outcome, and still desires to have the procedure, it should be considered.
  6. 6. Barium Enema
  7. 7. Endoscopic View
  8. 8. Operative Steps <ul><li>Colon & rectum mobilised </li></ul><ul><li>Terminal ileum transected flush with cecum </li></ul><ul><li>Rectum transected just above levator ani (5 cm from anus) </li></ul><ul><li>Root of small bowel mesentary mobilised upto pancreas </li></ul>
  9. 9. Mobilisation of Ileum: Dissection till root of SMV (pancreas) ICV ligated, Serosal incisions
  10. 10. Different Pouches S Pouch J Pouch W Pouch
  11. 11. Operative Steps (J-Pouch)
  12. 12. Linear Cutter 55
  13. 13. Stapling Technique:
  14. 14. J Pouch
  15. 16. Linear Stapler 60
  16. 17. Rectal Transection 5cm from anus
  17. 18. Stapled Rectal Stump
  18. 19. End to End Anastomosis (EEA) Stapler 29
  19. 20. Technique of EEA
  20. 21. Anvil placed at the apex of J pouch with purse string sutures
  21. 22. Stapler introducer P/R
  22. 24. Both ends are joined
  23. 25. Stapler closed & fired
  24. 26. Both Doughnuts
  25. 28. AIM End Result
  26. 29. Case-1 Case-2
  27. 31. Case-1 Case-2
  28. 32. IPAA: Without Loop Ileostomy <ul><li>Surgery proceeded smoothly without contamination </li></ul><ul><li>Good hemostasis </li></ul><ul><li>No adverse features for anastomotic healing </li></ul><ul><li>(high dose steroids, malnutrition, medical factors) </li></ul>Covering stoma is safer in early learning phase
  29. 33. IPAA: With Omentectomy <ul><li>Adheres to small bowel & abd. Wall. </li></ul><ul><li>Becomes fenestrated leads to intestinal Obstruction. </li></ul><ul><li>If relaparotomy required causes difficulty in dissection. </li></ul>After colectomy omentum becomes abdominal “ busybody” resulting in more harm than help.
  30. 34. Postoperative Advises <ul><li>Be aware of added Symptoms & risk factors for dehydration (hot weather, exercise, air conditioning) </li></ul><ul><li>Maintain adequate oral liquid intake </li></ul><ul><li>Avoid high solid fibre diet for 6 wks </li></ul><ul><li>Use bulk forming agent </li></ul><ul><li>Use Loperamide Hydrochloride </li></ul><ul><li>Anastomotic finger examination/dilatation every 6wks </li></ul>
  31. 35. Results <ul><li>Quality of life </li></ul><ul><li>Frequency: day and night </li></ul><ul><li>Perfect continence </li></ul><ul><li>Fecal spotting </li></ul><ul><li>Taking all food orally </li></ul><ul><li>Wt. gain </li></ul>
  32. 36. THANKS