Operative Technique

The initial incision, abdominal exploration, mobilisation and dissection of the colon are similar to that

Rectal Eversion

Fig. 8. Restorative proctocolectomy: J-pouch and mechanical end-to-end ileo pouch-anal anastomosis (IPAA)

for total colectomy. When the colon has been full mobilised and the mesentery has been divided, the patient is placed in a steep Trendelenburg position. The presacral space is entered by dividing the left and right pararectal peritoneum. The plane is developed posteriorly and laterally. Anteriorly in male patients, care is taken to identify seminal vesicles, fascia and prostate. The rectum is circumferentially dissected down to the pelvic floor and transected with an articulate linear stapler positioned 1-2 cm above the dentate line. Although various reservoir designs have been described, it was not until 1978 when Parks et al. [61], from St. Mark's Hospital of London, reported their experience with the triple-folded S-shaped reservoir that the modern era of the IPAA began. Several other reservoir designs were later proposed, including the double-folded J-shaped reservoir, the four-folded W-shaped reservoir, the later lateral reservoir of Fonkalsrud, and the U-shaped reservoir. The ileal J-pouch described by Utsunomiya et al. [62] has become the most popular because of its simplicity and functional outcome. The distal 30-40 cm of the ileum is looped approximating the antimesen-teric borders of the bowel forming a "J" loop, with 15-to 18-cm limbs and a reservoir capacity of approximately 400 ml. The 75-mm or 100-mm linear cutting stapler is inserted through a stab wound into the antimesenteric border of the ileum at the apex of the lumen, thereby dividing the common wall between the two limbs. The procedure is repeated using the same opening until pouch construction is complete. The anastomotic staple line is inspected for haemostasis. The pouch will reach the pelvic floor without vascular tension if its apex can be pulled 3-5 cm below the upper aspect of the pubic symph-ysis. It may be necessary to score the visceral peritoneum along the superior mesenteric artery and, sometimes, to transect the ileocolic vessels or a few proximal branches. If the region of anastomosis is difficult to reach, an S-pouch may be used, avoiding too long an efferent limb with functional outlet obstruction. By transecting the rectum at the level of the levators, a short mucosectomy can be performed transanally from the dentate line, leaving a short muscular cuff. The tip of the pouch can be sewn by hand at the level of the dentate line [50, 51], sometimes after rectal eversion according to the technique published by Panis et al. [63].

To simplify the operation and with the hope of improving continence, many surgeons prefer to transect the upper anal canal as close to the dentate line as possible and perform a stapled anastomosis. A manual purse-string suture is placed around the tip of the pouch, the head of a circular stapler is inserted into the lumen of the pouch and the purse-string suture is tied. The pin of the stapler is placed upward through the anus. The instrument is closed, and the stapler is fired to anastomose the pouch to the anus [25]. If the pelvic floor is difficult to reach, a straight IAA may be rarely carried out with lower continence rate and poor patient satisfaction.

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