There are several clinical scenarios when the operation of ileal pouch-anal anastomosis does not go as smoothly as planned, specifically with respect to obtaining enough length to construct an anastomosis. Although the technique of stapled ileal pouchanal anastomosis has greatly facilitated the ability to obtain additional length, there are still situations in which this is technically difficult. In addition, there are situations in which a hand-sewn anastomosis is required, for example, in the UC or FAP patient with a low-lying rectal cancer, or the patient who has had a very short Hartmann pouch where, due to distal scarring, a stapler technically cannot be used to create an anastomosis. The most common situations in which it will be difficult to gain enough length to perform an "easy, tension-free anastomosis" are:  those patients who are obese,  those in whom reoperative surgery is performed and who have foreshortening of the mesentery due to scar tissue,  those patients who, based on their body habitus, have an unusually short small-bowel mesentery,  patients with an unusually long torso,  patients with familial adenomatous polyposis (FAP) who have mesenteric desmoid disease, as well as  patients who for a variety of reasons have undergone prior small-bowel resection. In these situations, particular attention to detail with respect to mobilization of the small-bowel mesentery and certain technical tips can be extremely helpful in facilitating the course of the operation. This chapter will be divided into two sections, the first dealing with maneuvers to help gain additional mesenteric length and allow the terminal ileum and J-pouch to reach the anal canal more easily and the second, with maneuvers to facilitate construction of a loop ileostomy in these individuals, which can itself be extremely difficult.
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