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