Ileal Pouch-Anal Anastomosis

Tracy Hull

Perioperative Considerations

Construction of the J and S Pouch

A total proctocolectomy and ileal pelvic pouch has become the gold-standard operation for ulcerative colitis (UC) and familial polyposis (FAP) requiring surgical intervention.
It is also offered to select patients with Crohn colitis (CC) without small bowel or anal disease.
Preoperatively, all patients should have their anal muscle assessed with a digital examination to ensure they will be able to control the liquid stool produced from a pelvic pouch.

Considerations for UC

Biologic medications have been utilized almost uniformly in patients with UC at least over the past 10 years.
- This class of medication has been used in combination with other immune modulators, and patients refractory to medical management many times are referred to the surgeon in suboptimal overall health.
- Therefore, it has become more common to perform a three-stage procedure.
Patients with dysplasia offer another challenge.
- If the dysplasia is in the colon, we would typically perform (ourselves not the gastroenterologist) many biopsies of the distal rectum and anal transitional zone and if no dysplasia offer a double stapled pouch.

Considerations for FAP

Before considering a pelvic pouch, perform an endoscopy on the rectum.
- If there is a low number of polyps, a colectomy and ileorectal anastomosis may be considered.
An esophagogastroduodenoscopy with a scope that has side viewing capability is performed looking for duodenal adenoma.
More importantly, a family history of desmoids and a computed tomography looking for desmoids should be considered.
- A mesenteric desmoid may preclude doing a pouch.

Considerations for CC

In select and motivated patients with CC, we typically would perform a colectomy.
If there is no small bowel disease and no anal disease for at least 1-2 years after colectomy, a pelvic pouch can be considered.

Other Perioperative Considerations

Preoperative subcutaneous heparin is administered within 2 hours of surgery, and sequential compression devices are used to help prevent deep venous thrombosis prophylaxis.
Pelvic ureteral stents are selectively used, but not typically needed.

Sterile Instruments and Equipment

10-mm balloon port
3 mm × 5 mm ports, 1 mm × 12 mm port
10-mm 30-degree camera
5-mm laparoscopic blunt-tip bipolar energy device
3 mm × 5 mm laparoscopic atraumatic bowel graspers with locking ratchets
5-mm laparoscopic scissors with bipolar cautery attachment
Extra-long (bariatric) laparoscopic atraumatic bowel graspers and scissors available for morbidly obese patients
5-mm laparoscopic Maryland grasper or laparoscopic Allis clamp
End-to-end circular stapler 28-31 mm
Laparoscopic linear stapler 45-60 mm
Bean bag (optional)

Patient Positioning

Begin in the supine position.
After induction of anesthesia, adopt the Lloyd-Davies position: ensure perineum just overhangs operating table edge, with legs in Yellowfins stirrups.
Arms should be tucked next to torso, with foam padding used to prevent any pressure injuries at the hands and pressure points. In obese patients, the left arm may be left on an arm board.
Knees should be flexed to approximately 30-40 degrees.
Lower the Yellowfins so that the thighs are almost neutral to the torso to ensure adequate space for laparoscopic instruments to reach the splenic flexure.

Technique

Double-Staple “J” Pouch

Stage 1—a subtotal colectomy is performed—typically laparoscopically.

For an open procedure, a midline incision is chosen.
Trocars for laparoscopic surgery vary as to the preference and skill set of the surgeon. Some also use a single port or robot. One choice for trocars is shown in Figure 40-1.

FIGURE 40-1 ▪ Possible trocar placement for laparoscopic surgery.

We vary in our handling of the rectal stump, depending on the degree of inflammation/status (ie, friability) of the bowel. The traditional way is to embed it the distal aspect of the incision or the extraction site (if laparoscopic). That way if the staples do not hold, it avoids a disastrous pelvic infection (Fig. 40-2).

FIGURE 40-2 ▪ The rectal stump is sewn to the undersurface of the extraction site (laparoscopic) or lower midline incision (open). (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Typically, the inferior mesenteric pedicle is left in place.
- Another method is to divide the rectum at the sacral promontory, oversew the staple line, and leave a pelvic and transanal drain.

Stage 2—completion proctectomy and pouch +/− diverting ileostomy (modified stage 2)
- This stage is typically performed ˜4-6 months following the colectomy. This allows the patient to stop taking steroids and immune affecting medication and regain their health.
- The patient is placed in stirrups or split legs. If a mucosectomy is to be done, stirrups are chosen.
- There is no specific bowel preparation.
- The patient should receive preoperative intravenous antibiotics.
- If the patient has had oral steroids within 3 months, we will consider giving a preoperative dose of 100 mg of hydrocortisone.
  - Our goal is to use the least amount of steroids in the perioperative period.
The stage can be done open, laparoscopic, combined laparoscopic/transanal, or robotically, depending on the skill set of the surgeon.
Trocar placement is similar to what is shown above and often use the previous sites.
An incision is made over the embedded stump (if applicable). The rectal stump is mobilized free and replaced in the abdomen.
The ileostomy is carefully taken down to avoid loss of bowel and length. It is tied off and returned to the abdomen if laparoscopic or packed in the upper abdomen if open (Video 40-1).
One method to continue access is to place an extra-small wound protector in the ileostomy site and a small or medium in the suprapubic incision (Fig. 40-3).

FIGURE 40-3 ▪ A wound protector is placed through the stoma site.
A 10- to 12-mm trocar is placed inside the wound protector (Fig. 40-4).
It is loosened a bit, and a Penrose is tied around the outside the wound protector. To seal the area, penetrating towel clips (usually two) are placed on one side, and pneumoperitoneum is established (Fig. 40-5).

Under direct vision, the other 5-mm trocars can be placed (Fig. 40-6).

FIGURE 40-4 ▪ The 10- to 12-mm trocar is placed through the wound protector.

FIGURE 40-5 ▪ A Penrose drain is placed around the outside and held tight with an instrument. Penetrating towel clips are placed along the side, which prevents the pneumoperitoneum from escaping.

FIGURE 40-6 ▪ All trocars placed and ready to begin.

After incision or trocar placement, all adhesions are lysed, and the ileocolic pedicle and small bowel mesentery are mobilized beneath to the duodenum.

To improve reach, the ileocolic artery can be divided being cautious to avoid injury to the arcade that is close to the bowel-mesentery junction as that will be the blood supply for the future pouch. This can also be done just before pouch construction.

Also, if reach is a problem, small incisions can be made over the peritoneum covering the vessel to allow more mobility (Fig. 40-7).

FIGURE 40-7 ▪ To enhance reach, the ileocolic vessel can be divided. However, the marginal vessel must remain intact. Also, small slits can be made over the perineum to allow for more reach. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

The rectal stump is identified (Video 40-2).
The patient is placed in steep head down, and adhesions are lysed in the pelvis.
Dissection is begun in a similar manner as when doing a total mesorectal excision for rectal cancer. The inferior mesenteric vessels do not need to be ligated flush with the aorta, and the envelope of fat may be more difficult to dissect in the pelvis if there has been a lot of inflammation, but essentially dissection is carried out in the presacral space after the inferior mesenteric vessels are ligated. Hence, the rectal mesentery is removed.
If this is a second stage procedure, all mesentery cephalad is divided.

We ensure we have dissected to the pelvic floor by placing an index finger in the anus with the other hand in the pelvis or laparoscopically a clamp in the pelvis, to verify full mobilization of the rectum to the pelvic floor.

When the mobilization is to the level of the pelvic floor, the rectum is stapled. We use a 30-mm stapler if open with the goal of a 1-1.5 cm anal transitional zone (Figs. 40-8 and 40-9). For the robotic or laparoscopic approach, we strive to use the least number of fires with the laparoscopic linear stapler (Video 40-3).

FIGURE 40-8 ▪ The rectal stump is divided at the pelvic floor with a goal of a 1-1.5 cm anal transition zone. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

FIGURE 40-9 ▪ A sagittal view of placing the stapler to ensure a short anal transition zone. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

An extraction site is chosen (for laparoscopic surgery), which is usually the old stoma site or a suprapubic site.
The rectum is removed via the extraction site.
The small bowel is brought onto the abdomen. It is measured to provide a 15-20-cm-limb J pouch. Again, if there is a question of reach particularly in the open technique, a long instrument can grasp the curved part of the J and verify reach (Fig. 40-10).

FIGURE 40-10 ▪ Reach to the pelvis can see assessed for the planned pelvic pouch by grasping the small bowel 15-20 cm upstream from the distal most point and pulling down to the pelvic floor. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Construction of the J Pouch

For open procedures, drape off the abdomen to avoid spillage.
For laparoscopic procedures, the pouch can be typically constructed through the ileostomy site.

An enterotomy is made in the curved part of the J. The gastrointestinal anastomosis (GIA) 100-mm stapler is carefully inserted and fired after assuring the mesentery is not caught (Fig. 40-11).

FIGURE 40-11 ▪ Various stages of construction of the ileal J pouch. An enterotomy is made in the curved part of the J. It takes two to three firing of the gastrointestinal anastomosis 100 to complete the pouch. The tip of the J area should not be long. The spike is brought out the rectal staple line. The gun is mated, and the anastomosis constructed. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Typically, it takes two to three fires of the GIA to construct the pouch. The open end at the tip of the J is closed with a 30-mm stapler, ensuring that is it nearly flush with the end of the GIA staple line to avoid a long tip of J segment.
3-0 absorbable suture is usually used to oversew the 30-mm staple line as it tends to bleed. Also, a simple suture is placed in the confluence of the two limbs to anchor the tip of the J end to the afferent limb. Care is taken when placing this suture as not to kink or narrow the afferent limb inlet. Some surgeons prefer to oversew the entire linear staple line with 3-0 absorbable suture in a Lembert manner.
The pouch is insufflated with air or saline to ensure it is water tight and distends adequately.
A purse string is placed in the enterotomy site at the curved part of the J, and the head of the gun is placed and tied down (Video 40-4).

Before placing the gun in the anus, four Allis clamps are placed around the anus to efface the anus and aid in the gentle insertion of the stapler (Fig. 40-12).

FIGURE 40-12 ▪ Four Allis clamps can be placed on the anus to efface the anal canal. This assists in gun insertion with tight anal muscles and a short distance to the staple line. It is easy to push the gun through the staple line.

It is very easy to inadvertently shove the stapler though tight anal muscles and through the rectal staple line. These effacement clamps reduce the amount of pressure needed to go through the anal muscles.

Care is taken intra-abdominally to push the sphincter muscles away from the short rectal stump and avoid incorporation into the staple line.

The anastomosis is completed in the usual manner, but ensuring that the pouch mesentery is straight and no extraneous tissue is in the staple line. It is optimal for the spike to protrude at the underside of the staple line that assists in avoiding catching vagina or other anterior structures (Fig. 40-13).

FIGURE 40-13 ▪ The spike is extended carefully. Aiming for the spike to penetrate just posterior to the staple line will assist in keeping anterior structures out of the circular staple line. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Laparoscopically, it is easy to twist the pouch mesentery 180 or 360 degrees. To ensure the mesentery is straight, all the small bowel should be on one side (usually the left abdomen) with the cut edge fully viewed from origin to distal pouch and verified to be straight.
The anvil is mated with the spike. As the stapler is closed, it is important to guide the pouch into the pelvis as the pouch can turn easily 180 degrees as the gun is closed (Video 40-5).

The stapler is fired, and doughnuts are checked. We also look for a leak by doing pouch endoscopy or pumping air in the pouch with saline in the pelvis looking for bubbles (Fig. 40-14 and Video 40-6).

FIGURE 40-14 ▪ The anastomosis is checked by insufflating air in per anus into the pouch with saline in the pelvis. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

A suction drain is placed in the presacral space.
For a three-stage procedure, an ileostomy is constructed upstream. For a modified two-stage procedure, no ileostomy is constructed.

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