0
Operative Technique |

Restorative Proctocolectomy With J-Pouch Ileoanal Anastomosis

Fabrizio Michelassi, MD; Roger Hurst, MD
Arch Surg. 2000;135(3):347-353. doi:10.1001/archsurg.135.3.347.
Text Size: A A A
Published online

Restorative proctocolectomy with ileoanal anastomosis, complemented by a pouch formed with the last foot of terminal ileum, is the procedure of choice for patients in need of surgical treatment for ulcerative colitis and familial polyposis. The procedure has undergone many technical modifications that have ensured a very high degree of continence and an acceptable number of daily bowel movements. Herein we describe the operative technique we use in the majority of our patients, a restorative proctocolectomy with hand-sewn J-pouch ileoanal anastomosis with protecting ileostomy. We also comment on the immediate postoperative care and on the long-term functional results.

Figures in this Article

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours

Figures

Place holder to copy figure label and caption
Figure 1.

Line of transection of the mesentery of the colon.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Division of the presacral areolar tissue.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Oblique view of the spatial relationship between parasympathetic and sympathetic nerves and rectum. Inset, Plane of dissection around the rectum: posteriorly between the presacral fascia and the fascia propria of the rectum, anteriorly between the rectum and Denonvillier fascia, and laterally as close as possible to the rectum so as to avoid injury to the parasympathetic and sympathetic nerves where they join to form the pelvic plexus.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Upward retraction on the rectum to place tension on the most caudad extension of the lateral ligaments.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Complete mobilization of the rectum down to the level of the levator ani muscles.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

To maximize mesenteric length, the peritoneum overlying the most distal branch off the superior mesenteric artery can be released with small perpendicular incisions.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

A longitudinal enterotomy is performed on the proximal limb opposite to the end of the distal limb for a length that approximately equals one half the circumference of the intestine. The lubricated forks of an 80-mm linear stapler are inserted (A) and locked (B). C, The mesentery of the terminal ileum is checked to make sure it has not been included in the stapler, after which the instrument is fired.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 8.

A, After removal of the stapler, the pouch is everted by applying Babcock clamps until the remaining intact septum is reached. B, A new 80-mm stapler is inserted. This maneuver is repeated 3 or 4 times, as necessary. The pouch is everted more after each subsequent firing by way of application of the Babcock clamps. C, It is common to require a 50-mm linear stapler to suture and divide the most distal portion of the septum, which has been encircled by passage of a right-angle clamp. D, Once the pouch is totally everted, the 2 suture lines are inspected for hemostasis.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 9.

The pouch is reduced by gentle traction on the apical stitch and countertraction on the edge of the original enterotomy.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 10.

Stay sutures are applied at the end of the linear suture lines to aid in the closure of the remaining enterotomy. Although such a closure could be performed with a linear stapler, the asymmetry of the defect can be better compensated by a hand-sewn closure.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 11.

The mucosectomy is started at the level of the dentate line and it is carried out over the internal sphincter.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 12.

Positioning of the pouch in the pelvis. In its final position, the pouch should lie in the pelvis with its antimesenteric side resting on the concavity of the sacrum and the afferent loop on top of the mesentery.

Graphic Jump Location

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 9

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles
Jobs
brightcove.createExperiences();