Kock Pouch (K-pouch)

Sherief Shawki

Perioperative Considerations

Patients should be counseled extensively about the expected function, needs, and potential revisions or failures that may be required with the operation.
ETS (enterostomal therapy nurse) will educate and mark the patient for the appropriate place.
Patients should undergo a mechanical bowel preparation with oral antibiotics.
Prior to surgery, the patient is given intravenous (IV) antibiotics and subcutaneous heparin.

Patient Positioning

Patients are positioned in Lloyd-Davies position with stirrups (Yellowfins or similar); alternatively, a split-leg table may be utilized.
- Access to the perineum should be readily accessible in cases where resection of a rectum or pouch is a concomitant part of the procedure.
The patient’s arms may be out or tucked at their sides bilaterally and padded appropriately to avoid nerve injury.

Approach and Equipment

These operations are generally not suited for minimally invasive techniques, and as such, an open approach is warranted.
Ureteral catheters may be utilized, when appropriate.
Standardized laparotomy set with open instruments
Wound protector
Bookwalter retractor
Appropriate lighting
PI-55 mm reusable noncutting linear stapler with green load ×3
3-0 Vicryl sutures
2-0 Ticron sutures
Water tube
JP drain

Technique

An open midline incision is performed along with generalized abdominal exploration.
Extensive lysis of adhesions should be performed from ligament of Treitz to the terminal ileum.
- This includes intraloop adhesions, especially in the terminal ileum, to facilitate construction of the pouch.

Pouch Creation

Begins with planning the length needed for pouch and the valve.

Starting from the terminal ileum, ˜15- to 18-cm-long efferent limb is marked. This is the future nipple valve and exit conduit (Fig. 46-1A-C).

FIGURE 46-1 ▪ A. Intraloop adhesions are lysed, and the bowel is prepared for pouch creation. B. Bowel is laid out in proper configuration. C. Measurements taken prior to create the K pouch. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Depending on the body habitus of the patient, additional centimeters may be needed to pass the efferent limb through the abdominal wall.
The excess will be resected at the end flush with the anterior abdominal wall.

This is followed by three loops of small bowel, which will become pouch reservoir; each measures ˜15 cm (Fig. 46-1B).
The three limbs are aligned together. A seromuscular suture is taken to oppose adjacent loops and keep them oriented (Fig. 46-2).

FIGURE 46-2 ▪ Seromuscular sutures taken to oppose adjacent two of the three loops of bowel.
The future enterotomy on the small bowel is marked with electrocautery for its entirety (Fig. 46-3).

FIGURE 46-3 ▪ Future enterotomy is marked with electrocautery. Note the two outer loops are slightly medial and the middle loop should be directly antimesenteric.
- It is important to keep the middle enterotomy in the middle of the bowel (ie, antimesenteric).
- The outer two enterotomies are slightly medialized, but still keeping enough bowel for the anastomosis.

The bowel is incised along the previously placed marks (Fig. 46-4A-C).

FIGURE 46-4 ▪ A. Opening of the enterotomy. B. Depiction of the three limbs and the enterotomy. C. Enterotomy continues along the bowel. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

An outer seromuscular layer of the posterior wall of the pouch is undertaken. This is done in a running manner, using 3-0 absorbable suture (Fig. 46-5).
The second inner layer of the posterior wall of the pouch to approximate the mucosa is completed using 3-0 polyglycolic acid suture in running manner (Fig. 46-6A and B).