Dr. Feza Remzi

Redo ileal pouch surgery for mechanical pouch dysfunction

Recognition and appropriate classification of pouch-related conditions is imperative for proper management-prognosis. Pouch complications are most often attributed to surgical and/or mechanical factors. These include leaks from the tip of the J pouch, body or anal anastomosis, often leading to chronic sinus formation, as well as pouch-vaginal fistulas. Acute angulation of the afferent limb at the junction of the pouch can lead to small bowel obstruction. In the following video we will present two uncommon causes of mechanical pouch dysfunction. Case 1 This is a patient who underwent a two-stage laparoscopic restorative procto-colectomy with an ileo J pouch, complicated by recurrent small bowel obstructions. As can be seen, the mesentery overlying the pouch is twisted 180 degrees, causing obstruction of the pouch. Here we can follow the proximal small bowel leading into the pouch. The mesentery is noted to have a 180-degree twist, overlying the proximal and distal small bowel, causing an obstruction of the pouch. This obstruction leads to chronic ischaemia of the pouch. The mesentery is detorsed, allowing the pouch to lie in its proper orientation. Case 2 This is a patient who underwent a laparoscopic restorative procto-colectomy with an ileal J pouch, who developed pouch obstruction attributed to anastomotic stricturing. As seen here, the ileum traverses through a retained mesorectum, which encases the patient’s conduit on the right-left sides. The encasing mesorectum limits the conduit’s ability to expand, often leading to difficulty with pouch evacuation. Technical aspects of Redo ileal J Pouch Surgery We will utilise this patient’s case history to review the technical aspects of a redo ileal J pouch procedure. Once the pouch has been mobilised from within the pelvis, four averting anal sutures are placed to facilitate exposure for detachment of the pouch from the perineum. The pouch is detached from the perineum and a mucosectomy is performed. The disconnected pouch with the surrounding mesorectum is then removed from the abdominal cavity. The surrounding mesorectum is excised off the ileum in preparation for the creation of a new J pouch. Lengthening maneuvers can be performed in order to facilitate a tension-free reach to the pelvis. Here the mesentery is mobilised to the level of the duodenum. Additional maneuvers not demonstrated in this video also include division of the ileocolic pedicle at its origin and a series of transverse incisions over the super-mesentery vessels to gain mesenteric length. Despite these maneuvers to mobilise the small bowel, our previously disconnected distal ileum cannot reach the symphysis pubis without undue tension. Alternatively, the patient’s prior loop ileostomy’s side easily reaches 4 to 6 cm below the symphysis pubis, and can be utilised. A new ileal J pouch is made using several reload firings of the ILA 100 stapler, creating a 20 to 25 cm pouch. The redundant efferent limb of small bowel is then excised using a PI30 stapler in oversewn. The staple line is inspected for bleeding and the pouch is insufflated with saline to ensure no leak. An assistant then passes a Babcock clamp through the anus and the pouch is delivered through the anus. Interrupted 2-0 Vicryl™ sutures are placed in a radial fashion around the anus and a handsewn ileo-pouch anal anastomosis is made. Though a technically demanding procedure, we do ileo J pouch surgery with good outcomes with appropriate expertise and well-selected patients.