BACKGROUND
Ileoanal pouch surgery is the preferred option following a proctocolectomy for ulcerative colitis and familial adenomatous polyposis, with the ‘J’ pouch favoured by most surgeons. The pouch is anastomosed to the anus following complete excision of the rectum and its mucosa.1,2 Techniques to lengthen the mesentery include pouch folding,3 mesenteric incisions and division.4 For a tension free anastomosis, the pouch should extend 6cm below the pubic symphysis.5 We describe a technique to lengthen the ‘J’ pouch that avoids mesenteric surgery.
TECHNIQUE
Most ‘J’ pouch enterotomies are made at the apex of the pouch, allowing introduction of the stapling device. This usually corresponds with the point on the ileum with the greatest reach. It was observed that once the pouch is created, extra dependency is obtained by closing the original enterotomy and recreating it approximately 4cm proximal to the apex on the antimesenteric border (Figs 1 and 2). This allows for an extra 4cm of reach. Even if the original enterotomy is made at the very tip of the apex, a further 2–3cm are achieved. This is due to the increased ability for ‘stretching’ of the surrounding bowel wall, no longer impeded by nearby mesentery.
Figure 1.
The increase in length obtainable by creating a new opening 4cm proximal to the apex on the antimesenteric border, compared to the original opening
Figure 2.
The new longer pouch: Sutures are in place where the original enterotomy was closed
DISCUSSION
With the described technique all subsequent pouches have reached to the dentate line without the need for mesenteric manoeuvres. Mesenteric manipulation risks vascular compromise. We have experienced no complications related to this technique. It is simple to perform and increases reach by approximately 4cm, which is comparable to other techniques.5
References
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