LosTERRYblesBooKTeaM

LosTERRYblesBooKTeaM

LosTERRYblesBooKTeaM

LosTERRYblesBooKTeaM

LosTERRYblesBooKTeaM

INDICATIONS
A permanent ileostomy following removal of the colon can be avoided in selected patients by
removing all diseased colon down to the top of the columns of Morgagni or the pectinate line,
followed by construction of an ileal reservoir, with anastomosis of the anal canal (Figure 1).
Patients with ulcerative colitis and polyposis are candidates for this procedure, but those with
Crohn's disease are not, because of the potential for involvement of the small intestine. The
patient must have an adequate anal sphincter by digital examination or, better yet, by
manometry. The rectum should be free of ulcerations, abscesses, stricture, fissures, or
fistulae. This is especially important in patients with ulcerative colitis. This procedure can be
considered in patients who are strongly opposed to an ileostomy and who are available for
prolonged close follow-up. The patient should thoroughly understand the uncertainties of

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postoperative anal control and the need to have patience during the early months after the
operation. The procedure is usually not recommended for patients over 55 years of age.
Obesity may make it impossible to perform the anal pouch anastomosis without jeopardizing
the blood supply of the anastomosis.
Various surgical procedures have been used in an effort to improve longterm anal continence.
It is questionable whether any procedure currently used is always completely successful, and
the patient should be informed of this uncertainty. Increasing experience suggests the use of
some type of anal pull-through procedure has a reasonable chance of providing more comfort
than the terminal ileostomy or the ileal abdominal pouch.
A prolonged period of preoperative hyperalimentation or nonalimentation with catabolism may
be avoided by a staged procedure, especially in the presence of toxic megacolon, poor
general condition, or rectal disease. A permanent ileostomy is performed with subtotal
colectomy, leaving the rectum in place. After a year or more, an ileoanal anastomosis is
considered, with eventual closure of the ileostomy. Various pouches have been advocated.
They include the J pouch (Figure 2, A), the three loop S pouch (Figure 2, B), the lateral
isoperistaltic ileal reservoir (Figure 2, C), and the four-loop W reservoir (Figure 2, D).
PREOPERATIVE PREPARATION
Documentation of the pathologic process involved is done with biopsies taken from the anal
canal as well as the rectum or colon. The stomach and duodenum are inspected by
gastroduodenoscopy. The colon as well as the small intestine should have radiologic
evaluation with barium studies. Patients with polyposis should be informed of the potential for
malignancy. It is important to have medical and surgical agreement that surgical removal of
the entire colon is in the best long-term interest of the patient. Time is usually required for the
patient to accept the recommendation and the patient can benefit from talking with another
patient who has undergone this procedure. The patient's medications, including steroid
therapy for ulcerative colitis, must be considered, and steroid therapy continued. Intravenous
antibiotics are given before operation, and any major blood volume deficit is corrected.
Patients receive a clear liquid diet for a day or two and a rectal irrigation on the morning of
operation.
In severe cases, some prefer a 6-week period of intense medication to keep the colon at rest
permitting the inflammatory reaction to subside. Such patients may be placed on total
parenteral alimentation, systemic steroids and steroid enemas, and systemic antibiotics when
ulcerative colitis is present. The rectal mucosa is evaluated by sigmoidoscopic examination
immediately prior to the operation. A large rectal tube is placed for irrigation with saline and
povidone-iodine antiseptic solution.
ANESTHESIA
General endotracheal anesthesia is preferred.
POSITION
The patient is placed in the modified lithotomy position using Allen stirrups. This allows the
abdominal as well as perineal dissections to be performed without repositioning of the patient.
OPERATIVE PREPARATION
The rectum is given a very limited low-pressure irrigation, and the perianal skin and buttocks
are given the routine skin preparation. Constant bladder drainage is instituted and a
nasogastric tube is inserted. The pubis and abdominal skin are also prepared in the routine
fashion, and sterile drapes are applied.
INCISION AND EXPOSURE
A lower midline incision that extends to the left of the umbilicus is made, and the abdomen is
explored. Particular attention is given to the entire small intestine to make certain there is no
evidence of Crohn's disease, which would contraindicate the operation. The involvement of
the colon with inflammation or polyposis is evaluated. In the presence of polyposis, the
possibility of encountering an unsuspected site of malignancy or metastases to the liver is
ever present. If there is any question of Crohn's colitis, the colon is resected and sent to the
pathologist for gross and microscopic verification.

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DETAILS OF PROCEDURE
The colon may be constricted, friable, and quite vascular, with firm attachments to the
omentum. Gentle traction is applied to avoid tearing the friable bowel with resulting gross
contamination. The mesentery of the colon can be divided and blood vessels ligated relatively
near the bowel wall, except in diffuse polyposis, where there is always a possibility of
metastases to regional lymph nodes. It is judicious to have the pathologist evaluate the entire
specimen as soon as possible.
Before proceeding with the removal of the mucosa from the lower segment and before
constructing the ileal reservoir, it is essential that sufficient ileum has been mobilized to
construct the pouch. Approximately 50 cm of terminal ileum is required for the construction of
the ileal reservoir. Such mobilization is accomplished by dividing the ileocolic vessels and the
mesentery down to near the arcade of vessels at the very end of the ileum, but none of the
latter is ligated (Figure 3). It may be necessary to evaluate the mobility of the small bowel all
the way up to the ligament of Treitz with division of any bands that tend to limit the mobility of
the small intestine (Figure 4). Incisions within the posterior peritoneum may be worthwhile to
provide added mobility. Some divide the last ileal arcade as well as flex the patient at the hips
on the operating table in order to gain an easier length of the ileum in the pelvis (Figure 4).
The adequacy of the blood supply involved should be evaluated frequently to be certain a
vigorous blood supply is sustained to the end of the mobilized ileal terminal.
The dissection below the rectosigmoid junction is carried out close to the bowel wall to avoid
damage to the presacral and parasympathetic nerves. The rectal stump is washed out with
povidone-iodine, and the bowel divided at the anorectal junction. This leaves a stump about 3
to 4 cm in length (Figure 5). Some prefer to have a longer rectal anal stump, which requires
resection of the rectal mucosa from above rather than entirely through the anus. Others use a
stapling instrument for closure of the rectal stump.
Although the J pouch is most commonly used, a four-loop W pouch is illustrated to show the
generalized technique for combining multiple loops. One or more loops of ileum held together
by Babcock forceps are developed, each with a length of approximately 12 cm (Figure 6).
When a four-loop reservoir is made, the first loop is 3 cm shorter on the left side than the loop
on the right. A traction suture is placed in the apex of the most dependent antimesenteric
region of the slightly longer right-side loop. The surgeon passes this traction suture down
through the cleansed rectal stump to an assistant (Figure 6), who gently pulls the ileum down
to be certain this portion of the planned pouch can be easily sewed to the area of the dentate
line, while retaining a good blood supply. Some prefer to make the anastomosis along a line
at the top of the columns of Morgagni.
The W reservoir is constructed from the folder four loops, which are approximately 12 cm in
length, with the loop on the left 3 cm shorter than the right side. The loops are anchored in the
appropriate W position with Babcock forceps, as the seromuscular continuous sutures are
placed in three rows to secure the four segments of ileum (Figure 7). The antimesenteric
borders are incised in the four loops, and all bleeding points controlled either by sutures or by
electrocoagulation. The mucosa is closed with one continuous inverting suture (Figure 8). The
front of the reservoir is approximated with a one-layer closure using a continuous locked
suture after the staples on the divided end of the ileum have been excised and the end of the
ileum tailored with scissors to make it conform for an easier closure of the pouch. However,
the lower end of the incision below the two arrows is left open to readily admit two fingers.
This is the area to be anastomosed subsequently to the dentate line (Figure 8).
The mucosa is excised from the dentate line up to include the 3 or 4 cm of mucosa in the
rectal stump. Some prefer to outline the dentate line with electrocoagulation followed by the
submucosal injection of 1:300,000 adrenaline solution (Figure 9). This tends to elevate the
mucosa and facilitate the dissection in a more bloodless field. All mucosa must be completely
removed. This dissection is often the most time-consuming part of the technical procedure
and must be done with the greatest care (Figure 10). The underlying muscle and nerves must
not be injured. A dry field is essential.
Some prefer to grasp the stump with a Babcock forceps in the anus and everted out the anus
(Figure 11). This facilitates the removal of the mucosa under direct vision but may result in
poor fecal continence (Figure 12).
Others prefer to divide the mucosa at the top of the columns of Morgagni (see Anterior
Resection, Stapled, Figure 5). This avoids telescoping the rectal stump and lessens the

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possibility of nerve injury where the patient may not be able to differentiate stool from flatus
postoperatively. Last, some surgeons advocate leaving about 2 cm of mucosa above the
columns. Recurrence of inflammatory bowel disease and malignant degeneration are
possible and careful follow up is essential. In general, avoidance of rectal dilatation or
eversion of the stump plus a high level of anastomosis results in better fecal continence.
The adequacy of the blood supply to the reservoir is again double-checked. Two interrupted
sutures with needles attached (Figure 13) are anchored on each side of the two-finger
opening in the reservoir. These sutures are passed by the surgeon down through the anus,
and the reservoir is placed in the proper position from above.
The two sutures on each side are then anchored to either side of the opening at the level of
the dentate line (Figure 14). An additional suture is placed in the midline anteriorly and
posteriorly. Eight or ten additional sutures may be required to ensure an accurate
anastomosis. These sutures include the full thickness of the ileal wall, as well as a portion of
the internal sphincter (Figure 15).
Any openings in the mesentery are closed with interrupted sutures to avoid intestinal hernia.
The pelvic peritoneum is closed about the pouch to avoid twisting or displacement. A suture
may be placed to anchor the pouch to each side of the muscular rectal cuff to secure the
pouch in position and lessen the possible tension on the suture in the dentate line
anastomosis. Some prefer to insert a rubber drain between the wall of the pouch and the
rectal cuff. The rubber tissue drain is brought out anteriorly.
While it is tempting to avoid an ileostomy, fewer postoperative complications result if a
complete diversion of the fecal stream is accomplished by ileostomy. The defunctioning
ileostomy is performed through a small opening in the right lower quadrant about 40 cm from
the pouch (Figure 16). It is advisable to ensure complete diversion of the fecal stream (Figure
17) by intussuscepting up the proximal limb or stoma over the rod (see also Loop Ileostomy).
POSTOPERATIVE CARE
Antibiotics are continued until the danger of sepsis is passed. Steroid therapy is gradually
decreased until it can be omitted completely. The bladder catheter is removed after testing for
sensation after a few days. The diet is slowly increased, but may need to be adjusted or
limited depending upon the incidence of diarrhea.
Incidental obstruction, pelvic sepsis, and local problems around the ileostomy are occasional
complications after the operation. After a month, the integrity of the pouch and the anal
anastomosis is evaluated by radiographic procedures with contrast dye. Within two months,
the capacity of the pouch is measured, and rectal manometry studies may be repeated. If no
problems exist, the ileostomy is closed within four months.
The major consideration involves the degree of anal continence that has been achieved.
Patience is required during the first year, as the capacity of the pouch increases and
sphincter control gradually improves. The control of diarrhea during the day and soiling at
night are of major concern and may require adjustment in bulk and type of food, as well as
special medication. The number of daily stools varies, with an average of six per day and one
or two per night. Patients with polyposis usually have fewer bowel movements per day than
patients with ulcerative colitis.
A troublesome complication is a poorly defined syndrome known as pouchitis. The stools are
increased in frequency with malaise, fever, and bloody stools, along with abdominal cramps.
This complication is far more common in patients with ulcerative colitis than in those with
multiple polyposis. Specific medication and dietary adjustments are indicated. This procedure
is believed to be associated with chronic residual stasis. Intestinal obstruction may occur in
10 percent more of the patients.
Patients with this operation require frequent, long-term follow-up evaluations.

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