One of the key maneuvers in gaining length of the ileal J-pouch is complete mobilization of the small-bowel mesentery. The small-bowel mesentery adheres to the retroperitoneum in a diagonal fashion beginning in the lower right quadrant, extending upwards toward the left upper quadrant. The entire mesentery of the small bowel should be mobilized to the level of the second and third portions of the duodenum (Fig. 1). Division of the filmy adhesions between the small bowel mesentery and the duodenum permit additional stretch of the small bowel mesentery. In doing this maneuver, one must be careful not to do too much mobilization. Injudicious mobilization or use of electrocautery in the vicinity
of the pancreas can actually result in pancreatitis and should be avoided.
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