Division of Either the Ileocolic or Superior Mesenteric Blood Vessels

If the above maneuvers are still insufficient for providing adequate mesenteric length, some of the blood vessels supplying the terminal ileum can be divided. If the colectomy is performed at the same time as the ileal J-pouch anal anastomosis, it is important to pre

Fig. 2a-c. Peritoneal windowing to gain additional mesenteric length. a A hemostat is inserted underneath the peritoneum to lift it away from the underlying mesenteric blood vessels. b Electrocautery is then used to divide the peritoneum in a step-ladder-type fashion at regular intervals. c Several centimeters of additional mesenteric length can be gained using this maneuver

Fig. 2a-c. Peritoneal windowing to gain additional mesenteric length. a A hemostat is inserted underneath the peritoneum to lift it away from the underlying mesenteric blood vessels. b Electrocautery is then used to divide the peritoneum in a step-ladder-type fashion at regular intervals. c Several centimeters of additional mesenteric length can be gained using this maneuver serve the entire course of the ileocolic vessels. This is important so that, if additional mesenteric length is required, this vessel can be used as the main pouch blood supply. This is unfortunately not an alternative in patients who have already had a prior colectomy and present at a later stage for ileal J-pouch anastomosis. The terminal ileum is characterized by its arcade-like blood supply. Either the distal superior mesenteric or the ileocolic vessels can be divided, provided that the other blood vessels are intact and that good bowel perfusion can still be maintained via these arcades [1]. If there is inadequate mesenteric length, by placing distal traction on the J-pouch, one can easily ascertain by palpation alone whether the ileocolic vessels or the distal superior mesenteric vessels are under more tension. These vessels can be felt as tight cords or bands even in obese patients when the pulses of the vessels cannot easily be palpated. If one or the other of these vessels feels to be under more tension, these vessels can be clamped, divided and ligated and additional mesenteric length obtained. If there is a question as to what effect division of these vessels would have on pouch viability, vascular clamps can be used to occlude these vessels, and pouch viability ascertained before they are divided. With this technique, an additional 2-3 cm of mesenteric length can be attained.

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