This document discusses technical aspects of ileal pouch-anal anastomosis (IPAA). It describes the different types of pouches that can be constructed, including W and J pouches. It also discusses the surgical techniques for performing a laparoscopic IPAA, including port placement, mobilization of different parts of the colon, and creating the ileal-anal anastomosis. The document notes that a stapled anastomosis may have better outcomes than a hand sewn one. It also discusses topics like managing an emergency colectomy, the optimal site of the anastomosis, and techniques to lengthen the small bowel mesentery.

1. TECHNICAL ASPECTS
OF IPAA
PROFESSOR ABHIJIT CHANDRA
KING GEORGE MEDICAL UNIVERSITY
LUCKNOW

3. WHY ILEO-ANAL POUCH ?
PATIENTS DEMANDED IT
PUSHED SURGEONS TO FIND A WAY
“..rather die than having a stoma”

4. TYPES OF POUCH

5. W AND J POUCH
J W
Easy construction.
Benefits from staplers
Needs only 30-40cm of
ileum.
If long enough, function
well
Time consuming to
construct.
Difficult to do with
staplers.
Uses 50cm of ileum.
Only marginally better
than J pouch in stools
frequency

6. TYPES OF IPAA
RECONSTRUCTION
• DOUBLE STAPLED
• DOUBLE PURSE STRING SINGLE STAPLED
• HAND SEWN

7. LAP IPAA
PORTS PLACEMENT

8. ISOLATION OF IMA/IMC PEDICLE DIVISION OF VESSELS DIVISION OF LEFT MESOCOLON

9. SPLENIC FLEXURE
MOBILISATION
TRANSVERSE COLON MOBILISATION HEPATIC FLEXURE
MOBILISATION

10. ILEO-CECAL MOBILISATION RIGHT COLON MOBILISATION LIGATION OF ILEO-COLIC VESSELS

11. MOBILISATION OF RECTUM EXPOSURE OF LOWER RECTUM MOBILISATION OF LEFT COLON
AND RECTUM

12. LINEAR CONTOUR TO DIVIDE RECTUM AT
ANORECTAL JUNCTION
Digital evaluation to mark the level of planned stapled ileal
pouch-anal anastomosis

13. ANORECTAL DIVISION
THE ILEAL POUCH ANAL ANASTOMOSIS

14. VIDEO

15. Managing the rectal remnant in Emergency
Colectomy
• The whole rectum and the IMA should be preserved.
“facilitates subsequent pouch surgery”
• Ways to deal with stump:
Leave additional sigmoid colon
Closure of stump at fascia level (subcut stoma)
Mucus fistula
Rectal decompression with per rectal drain

16. Site of Anastomosis for restorative
proctocolectomy
• Distance between dentate line and anastomosis should not exceed 2
cm.

17. Hand Sewn or Stapled Anastomosis
• If done well: Stapled anastomosis seems to have better outcomes,
particularly with regard to soiling, faecal leakage and social
restriction.
• Risk of cuffitis (rarely pouch dysfunction), and risk of dysplasia (very
rarely cancer, <30 reported) with stapled anastomosis.
• Mandatory that the surgical team can also perform a mucosectomy
and a hand-sewn anastomosis should the stapled anastomosis fail.
• No room for re-stapling.
• In case of neoplasia complicating colitis : Stapled is equally safe.

18. Double stapled or double purse string
• Double stapled : 2 staple lines across each other, creating stapled dog
ears and ptentially ischemic areas.
• Single stapled double purse string: Eliminate intersection staple lines
and stapled corners.
• Slowamis and Marerick, AJS 2006, 160 non diverted/ non irradiated
patients underwent double purse string anastomosis:
96% : No pelvic sepsis
2.5%: Pelvic sepsis with no anastomotic defect
Leak : 1 patient

19. Role of covering ileostomy
• Emerging evidence: Defunctioning the distal anastomosis reduce the
incidence of a leak.
• Single stage IPAA: highly select cases
Thick or fatty abdominal wall
Short small bowel mesentery.

20. ROLE OF ILEO-RECTAL ANASTOMOSIS
• Considered only in special cases
• Concern for reasons of fertility).
• Long term surveillance is advised.

21. Intramucosal or Total mesorectal Excision
• Better fecal continence with intramesocolic excision.
• Similar overall bowel or sexual functions.
Hicks CW et al. AJS.2014

22. Lengthening Procedures
• Cadaveric studies have observed that if the apex of the proposed pouch can
reach 6, 4, or 2 below the symphysis pubis, then the pouch will reach the dentate
line without tension 100, 55, or 33 % of the time, respectively.
• Lengthening Procedures
1. Ligation of the IC, distal SMA or, less commonly, individual ileal mesenteric
vessels : 3-6 cm gain in length
2. Complete mobilization of the small bowel mesentery to the root of the SMA at
the pancreatic head
3. Step-wise ‘‘relaxing’’ incisions of the peritoneum over tension lines along the
pouch mesentery
4. Orienting the ileal pouch anteriorly within the pelvis
5. Using an S-pouch configuration.
6. Leave pouch in pelvis with proximal loop ileostomy