Performing stapled ileal J-pouch anal anastomosis is by far the easiest method with respect to mesenteric length, because in this situation, the transanally placed stapler pushes the perineum towards the abdomen and small-bowel mesentery, reducing the length needed by several centimeters compared to hand-sewn techniques. Purse string sutures are not reliable and frequently are placed incorrectly. Because of this, incomplete "doughnuts" are common. I prefer to use a triple-staple approach, in which no purse string suture is used . The anvil of the stapler is placed through the enterotomy through which the GIA staplers that created the J-pouch are fired. This enterotomy is in turn then closed using a linear stapler and the shaft of the anvil pierced through the bowel just adjacent to this linear staple line. Since no purse string suture is required, the bowel is less likely to tear and there are fewer technical problems with the anastomosis, especially if an anastomosis is constructed under tension. In the very obese patient, the extra-large straight St. Marks retractor is invaluable. This is particularly useful in the patient who is well over 150 kg (Fig. 3), and particularly in obese male patients in whom the narrow pelvis further makes dissection difficult. The only
compromise one may have to accept with a stapled ileal J-pouch anal anastomosis is that, in a very large patient, one may have to accept an anastomosis that would be higher above the dentate line than in the ideal situation. In these cases, surveillance may need to be performed more frequently and one must be prepared to perform a mucosectomy should this become necessary. This clearly becomes a very serious issue in the case of familial adenomatous poly-posis when one may also be dealing with patients who might not be compliant with follow-up surveillance. This must be discussed in great detail with patients preoperatively, particularly in the United States where many of these patients have a low rate of follow-up.
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