Peritoneal Windowing

The visceral peritoneum acts almost like a "sausage casing" in terms of holding in or confining the mesentery of the small bowel. If the visceral peritoneum covering the mesentery of the small bowel is sharply incised, the small-bowel mesentery stretches more easily. Because the blood supply to the ileal pouch is extremely important, much care needs to be taken when performing this maneuver. In order to do this, while avoiding injury to any of the underlying blood vessels, a very fine hemostat can be gently inserted underneath the peritoneum in order to lift it away from the underlying blood vessels and the elec-trocautery used to gently divide the peritoneum (Fig. 2a). This is done at 1 or 2-cm increments in a horizontal step-ladder-type fashion, while an assistant applies distal traction to the point of the terminal ileum that is chosen to be the apex of the J-pouch (Fig. 2b). As soon as the peritoneum is divided at each point, there is a gaping of the peritoneum in this area. When the anterior surface of the small-bowel mesentery's peritoneum is "windowed" in this manner, the small-bowel mesentery is then "flipped" or turned cranially so that it lies over the upper portion of the patient's abdomen and chest. Subsequently, the identical maneuver is then performed on the posterior aspect of the peritoneum covering the small-

bowel mesentery beginning just above the level of the third portion of the duodenum and proceeding distally towards the mesenteric portion of the segment of terminal ileum chosen to be the apex of the J-pouch. One can usually gain approximately 2-3 cm or more of additional mesenteric length via this maneuver (Fig. 2c).

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