Restorative Proctocolectomy With J-Pouch Ileoanal Anastomosis

Line of transection of the mesentery of the colon.

Division of the presacral areolar tissue.

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.

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

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

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

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.

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.

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

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.

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

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.