Post on 12-Apr-2017
Surgical challenges of lap pouch surgery
PM SagarThe John Goligher Unit
St James’s University Hospital,Leeds
Berlin Chirurgical Society 1933
Kock pouch
Ileal Pouch-anal Anastomosis
Straight ileoanal anastomosis
Continent ileostomy
Ileal pouch-anal anastomosis
Koch 1969
Nissen 1933
Ravitch & Sabiston 1955
Park & Nicholls 1978
Best1952
Design of the ileal pouch
S pouch
• Long efferent spout
• Self intubation in up to 50% of patients
Difficult reach
J or W pouch?
Design of the ileal pouch-anal anastomosis
• Double stapled
• Hand sewn
Hand sewn IPAA
Double stapled IPAA
Laparoscopic Ileal pouch procedure
Placement of the ports
Isolation of IMA & V pedicle
Vascular division
Left mesenteric division
Splenic flexure
Transverse colon
Hepatic flexure
Ileocaecal mobilisation
Right colon
Ligation of the ileocolic vessels
Mobilisation of the rectum
Exposure of the lower rectum
Mobilisation of the left colon & rectum
Linear contour to divide at the anorectal junction
Anorectal division
The ileal-pouch anal anastomosis
Pouchogram abnormalitiesin 80 lap pouches
• Anastomotic leak n=4 (3 healed on later study)
• Tight stenosis delaying closure n=3
• Leak from blind end of J pouch n=1
Pelvic sepsis
Pelvic sepsis after IPAA (early)
Minor
Anastomotic sinus
EUA + antibiotics
Pouchogram
?Delay closure
Pelvic sepsis after IPAA (early)
Minor
Anastomotic sinus
EUA + antibiotics
Pouchogram
?Delay closure
Major
CT guided drainage
Laparotomy
Wait 3 months
Revise
Healed Large cavityWait 3-12 mo
Anastomotic stricture
• Causes – sepsis, tension, ischaemia
• Significant in 5-16%
• More common in stapled vs hand sewn
• Mild / moderate – Rx Hegars dilators
Transanal pouch advancement
Transanal pouch advancement
Transanal pouch advancement
Pouch advancement
Pouch-vaginal fistula
Ileal pouch Vagina
Classification
MRI - pouch-vaginal fistula
MR - healed pouch-vaginal fistula
Transvaginal repair
Deterioration in pouch function
Pouchitis
Long efferent spout
Twisted pouch
Shrunken pouch
Mobile blind afferent limb
Pouch – fallopian tube fistula (Crohn’s disease)
Fistula tract
Upstream problem:small bowel stricture
Portal vein thrombosis
Failed stapling
Structural causes of pouch dysfunction
Summary
• Fully counsel your patient
• Attention to detail especially at IPAA
• Structured approach to pouch dysfunction
Pouchogram abnormalities
• Anastomotic leak n=4 (3 healed on later study)
• Tight stenosis delaying closure n=3
• Leak from blind end of J pouch n=1
Isolation of IMA & V pedicle
Left common iliac artery
Left ureter
IMA pedicle
Vascular division
Left mesenteric division
Transverse colon
Ileocaecal mobilisation
Vascular division
Exposure of the lower rectum
Lateral peritoneal reflection
sigmoid
Why Not?
• “It’s too hard”
• “It takes too long”
• “I can’t spare the time to learn”
• “I can’t train my registrars”
• “It’s too expensive”
Aims of the study
• Safety and long term outcome of cross stapling
• Critical level of the IPAA
Patients & methods
• Prospective database• July ‘06 - Dec ‘10
• 80 patients underwent IPAA under one surgeon
• Previous STC n=24
Patients
• J pouch
• All defunctioned
• Steroids < 15 mg /day
Results• Median operating time 210 mins (180-240)• Median time to reversal 4 mths (2-6)
• Height of IPAA = 3 cm (1-5)
• No incisional herniae• SBO n=2
Conclusion
Double stapled IPAA via limited Pfannenstiel incision at lap IPAA
is safe and at an appropriate anastomotic level