Introduction
There are several clinical scenarios when the opera- tion of ileal pouch-anal anastomosis does not go as smoothly as planned, specifically with respect to obtaining enough length to construct an anastomo- sis. Although the technique of stapled ileal pouch- anal anastomosis has greatly facilitated the ability to obtain additional length, there are still situations in which this is technically difficult. In addition, there are situations in which a hand-sewn anastomosis is required, for example, in the UC or FAP patient with a low-lying rectal cancer, or the patient who has had a very short Hartmann pouch where, due to distal scarring, a stapler technically cannot be used to cre- ate an anastomosis. The most common situations in which it will be difficult to gain enough length to per- form an “easy, tension-free anastomosis” are: [1]
those patients who are obese, [2] those in whom reoperative surgery is performed and who have fore- shortening of the mesentery due to scar tissue, [3]
those patients who, based on their body habitus, have an unusually short small-bowel mesentery, [4]
patients with an unusually long torso, [5] patients with familial adenomatous polyposis (FAP) who have mesenteric desmoid disease, as well as [6] patients who for a variety of reasons have undergone prior small-bowel resection. In these situations, particular attention to detail with respect to mobilization of the small-bowel mesentery and certain technical tips can be extremely helpful in facilitating the course of the operation. This chapter will be divided into two sec- tions, the first dealing with maneuvers to help gain additional mesenteric length and allow the terminal ileum and J-pouch to reach the anal canal more easi- ly and the second, with maneuvers to facilitate con- struction of a loop ileostomy in these individuals, which can itself be extremely difficult.
Maneuvers to Gain Additional Mesenteric Length
Mobilization of the Small-Bowel Mesentery
One of the key maneuvers in gaining length of the ileal J-pouch is complete mobilization of the small- bowel mesentery. The small-bowel mesentery adheres to the retroperitoneum in a diagonal fashion beginning in the lower right quadrant, extending upwards toward the left upper quadrant. The entire mesentery of the small bowel should be mobilized to the level of the second and third portions of the duo- denum (Fig. 1). Division of the filmy adhesions between the small bowel mesentery and the duode- num permit additional stretch of the small bowel mesentery. In doing this maneuver, one must be careful not to do too much mobilization. Injudicious mobilization or use of electrocautery in the vicinity
Management of the Difficult Ileal Pouch-Anal Anastomosis and Temporary Ileostomy
Susan Galandiuk
Fig. 1.Mobilization of the small-bowel mesentery up to the level of the third portion of the duodenum
of the pancreas can actually result in pancreatitis and should be avoided.
Peritoneal Windowing
The visceral peritoneum acts almost like a “sausage casing” in terms of holding in or confining the mesentery of the small bowel. If the visceral peri- toneum covering the mesentery of the small bowel is sharply incised, the small-bowel mesentery stretches more easily. Because the blood supply to the ileal pouch is extremely important, much care needs to be taken when performing this maneuver. In order to do this, while avoiding injury to any of the underlying blood vessels, a very fine hemostat can be gently inserted underneath the peritoneum in order to lift it away from the underlying blood vessels and the elec- trocautery used to gently divide the peritoneum (Fig. 2a). This is done at 1 or 2-cm increments in a horizontal step-ladder-type fashion, while an assis- tant applies distal traction to the point of the termi- nal ileum that is chosen to be the apex of the J-pouch (Fig. 2b). As soon as the peritoneum is divided at each point, there is a gaping of the peritoneum in this area. When the anterior surface of the small-bowel mesentery’s peritoneum is “windowed” in this man- ner, the small-bowel mesentery is then “flipped” or turned cranially so that it lies over the upper portion of the patient’s abdomen and chest. Subsequently, the identical maneuver is then performed on the pos- terior aspect of the peritoneum covering the small-
bowel mesentery beginning just above the level of the third portion of the duodenum and proceeding dis- tally towards the mesenteric portion of the segment of terminal ileum chosen to be the apex of the J- pouch. One can usually gain approximately 2–3 cm or more of additional mesenteric length via this maneuver (Fig. 2c).
Division of Either the Ileocolic or Superior Mesenteric Blood Vessels
If the above maneuvers are still insufficient for pro- viding adequate mesenteric length, some of the blood vessels supplying the terminal ileum can be divided.
If the colectomy is performed at the same time as the ileal J-pouch anal anastomosis, it is important to pre-
Fig. 2a-c.Peritoneal windowing to gain additional mesenteric length. a A hemostat is inserted underneath the peritoneum to lift it away from the underlying mesenteric blood vessels. b Electrocautery is then used to divide the peritoneum in a step-ladder-type fashion at regular intervals. c Several centimeters of additional mesenteric length can be gained using this maneuver
a
b
c
serve the entire course of the ileocolic vessels. This is important so that, if additional mesenteric length is required, this vessel can be used as the main pouch blood supply. This is unfortunately not an alternative in patients who have already had a prior colectomy and present at a later stage for ileal J-pouch anasto- mosis. The terminal ileum is characterized by its arcade-like blood supply. Either the distal superior mesenteric or the ileocolic vessels can be divided, provided that the other blood vessels are intact and that good bowel perfusion can still be maintained via these arcades [1]. If there is inadequate mesenteric length, by placing distal traction on the J-pouch, one can easily ascertain by palpation alone whether the ileocolic vessels or the distal superior mesenteric ves- sels are under more tension. These vessels can be felt as tight cords or bands even in obese patients when the pulses of the vessels cannot easily be palpated. If one or the other of these vessels feels to be under more tension, these vessels can be clamped, divided and ligated and additional mesenteric length obtained. If there is a question as to what effect divi- sion of these vessels would have on pouch viability, vascular clamps can be used to occlude these vessels, and pouch viability ascertained before they are divid- ed. With this technique, an additional 2–3 cm of mesenteric length can be attained.
Stapled Ileal Pouch-Anal Anastomosis
Performing stapled ileal J-pouch anal anastomosis is by far the easiest method with respect to mesenteric length, because in this situation, the transanally placed stapler pushes the perineum towards the abdomen and small-bowel mesentery, reducing the length needed by several centimeters compared to hand-sewn techniques. Purse string sutures are not reliable and frequently are placed incorrectly.
Because of this, incomplete “doughnuts” are com- mon. I prefer to use a triple-staple approach, in which no purse string suture is used [2]. The anvil of the stapler is placed through the enterotomy through which the GIA staplers that created the J-pouch are fired. This enterotomy is in turn then closed using a linear stapler and the shaft of the anvil pierced through the bowel just adjacent to this linear staple line. Since no purse string suture is required, the bowel is less likely to tear and there are fewer techni- cal problems with the anastomosis, especially if an anastomosis is constructed under tension. In the very obese patient, the extra-large straight St. Marks retractor is invaluable. This is particularly useful in the patient who is well over 150 kg (Fig. 3), and par- ticularly in obese male patients in whom the narrow pelvis further makes dissection difficult. The only
compromise one may have to accept with a stapled ileal J-pouch anal anastomosis is that, in a very large patient, one may have to accept an anastomosis that would be higher above the dentate line than in the ideal situation. In these cases, surveillance may need to be performed more frequently and one must be prepared to perform a mucosectomy should this become necessary. This clearly becomes a very seri- ous issue in the case of familial adenomatous poly- posis when one may also be dealing with patients who might not be compliant with follow-up surveil- lance. This must be discussed in great detail with patients preoperatively, particularly in the United States where many of these patients have a low rate of follow-up.
What to Do in Case of Extremely Difficult Hand-Sewn Anastomosis
Do not despair. Even in the most difficult circum- stance, do not give up and excise the anal canal. I have frequently seen this done, and know from per- sonal experience, that even in the most awful case when one thinks that all is lost, when one fears that there will be leaks and problems with healing, the anastomosis can still heal primarily and the patient obtain a satisfactory functional result. Even when the ileal J-pouch tears when it is brought down to the anal canal due to a large amount of tension on the anastomosis, it may still heal. One must, however, realize that the more tension there is on an anasto- mosis, the more likely the patient is to have a stric- ture postoperatively. It is therefore extremely impor- Fig. 3.Even in very large patients, ileal pouch-anal anasto- mosis can be performed. The extra-large straight St. Marks retractor is particularly helpful such as in this patient with a body mass index of 46.1
tant to check for this prior to loop ileostomy closure.
If this is not treated with dilation prior to loop ileostomy closure, there is a much higher risk of dehiscence of the loop ileostomy closure site. There is also a higher rate of pouchitis and chronic pouchi- tis associated with untreated strictures. Such stric- tures may only require digital dilation or dilatation under anesthesia [3]. When performing a hand-sewn anastomosis, it is very useful to first place quadrant sutures to fix the pouch to the anal canal before mak- ing a pouch enterotomy at the apex of the pouch for the anastomosis. A hand-sewn anastomosis with a complete mucosectomy should be performed in cases in which there is a distal rectal cancer, for example a distal rectal cancer in ulcerative colitis or FAP which does not permit a stapler to be placed below it due to its very distal location.
Loop Ileostomy Formation
If one is constructing an ileal J-pouch anal anasto- mosis under tension, it is extremely important to always divert the patient no matter how difficult it appears that creation of the stoma will be. Imagine how miserable a situation it would be if the patient would have an anastomotic leak and required reop- eration and diversion-it would be twice as difficult then. One must always optimize the conditions for successful anastomotic healing. If the anastomosis is created under tension, this includes diversion.
Preoperative Stoma Site Marking
It is extremely important to have the patient marked for a stoma site preoperatively [4]. This is most true in the obese patient and in the patient that has had pre- vious open surgical incisions. If the patient should have a problem with the distal anastomosis and require diversion for longer than the normal 8 weeks postoperatively, it is imperative to have a stoma locat- ed in a location where the appliance will be able to adhere for at least 2–3 days. In patients in whom the ileal J-pouch anal anastomosis is constructed under tension, the superior mesenteric vessels and blood supply leading to the ileal J-pouch is tethered close along the patient’s spine. This also tethers the vascu- lar arcades along the anti-mesenteric border of the distal small bowel, so that it can be very difficult to mobilize a loop of bowel to create an end ileostomy.
This will of course become easier as one proceeds proximally in the course of the small bowel. More proximal stoma placement will, however, be associat- ed with higher volumes of ileostomy output. Unfortu- nately, in very heavy patients, the best external site for
a loop ileostomy is often in the patient’s right upper quadrant, requiring that the loop of bowel chosen for the stoma to be located much more proximally than one would wish.
Ileostomy Aperture
When creating the skin aperture, making the aper- ture too small makes it technically difficult to mature the stoma, while making it too large makes it harder to obtain stoma eversion. In most patients, making a skin aperture roughly the same size as the diameter of the bowel to be used to create the stoma or several millimeters larger will provide for a suitably sized skin aperture.
In most patients, a two-finger breadth opening in the abdominal wall is all that is required for a loop ileostomy. However, in patients in whom there is excessive tension or particularly in obese patients, where the small-bowel mesentery may be very large, it is important to create a large enough fascial defect in order to permit the bowel to pass easily through the abdominal wall. Since this is a temporary ileosto- my, the larger fascial defect and the common paras- tomal hernia can easily be closed at the time of ileostomy closure.
Babcock or other types of clamps should be used for as brief a time as possible to grasp the bowel while it is brought through the abdominal wall. These clamps tend to rip through the bowel and cause an excessive amount of trauma even if they may be soft or “atrau- matic”. Once a clamp has been used to pass the bowel through the abdominal wall, it is quickly released and a dry gauze sponge or pad can be used to further manipulate the bowel, since this is much gentler to the bowel wall. If a significant amount of traction on the bowel is required, an umbilical tape passed immedi- ately underneath the bowel, just at its mesenteric mar- gin, will usually provide sufficient traction without disrupting the bowel wall, tearing it or interfering with or damaging its blood supply. One should always start with the small bowel just proximal to the ileal J-pouch and determine the most distal loop of small bowel that can reach and be adequately exteriorized through the ileostomy aperture. For an adequate loop ileostomy, 6–8 cm of bowel should be present above the skin sur- face depending upon the diameter of the small bowel.
Use of Stoma Rods
If there is excessive tension, a stoma rod may be used. I prefer short plastic ileostomy rods (Marlen).
These have the advantage that they are relatively small, being only several centimeters in length, so
that they do not interfere with the stoma appliance, as can larger rods that are meant for use with colostomies. Such rods should be left in place for 5 days after surgery in order to assure adherence of the bowel to the abdominal wall and subcutaneous tissue before removal. In a patient in whom a stoma is constructed under significant tension, these rods can easily cause a partial small-bowel obstruction when they are in place. It is not unusual that, due to this obstructed effect, the patient cannot be advanced beyond a liquid diet until the rod is removed. These rods also have the advantage of having an “eye” on both ends to permit them to be sutured to the skin so they cannot inadvertently “slip out” or be inadver- tently removed. If there is difficulty in physically get- ting the bowel to reach to the skin, in very rare cir- cumstances I have done a lipectomy of the area around the stoma site via the midline incision in order to “thin” the abdominal wall. This approach is used so as not to stretch the ileostomy skin aperture unduly. This is very rarely needed, since fat will almost always compress sufficiently and most obese patients have a fairly soft abdominal wall. One essen- tial in dealing with such patients is, however, to have them seen postoperatively by a skilled enterostomal therapist. These patients will invariably require a convex stoma appliance, Eakin seals, and a stoma belt. There are many different stoma supply manu- facturers. Some patients will even require very deep convexities or, appliances with special oval shapes.
Without the use of such appliances, ileostomy retrac- tion occurs. This is important, since, if retraction
occurs, the stoma will no longer be diverting and the patient then passes a large amount of stool through their J-pouch. This not only causes anal excoriation, but may also impair healing of the distal ileal J-pouch anal anastomosis, the prime purpose of the ileostomy in the first place.
Conclusion
In performing ileal pouch-anal anastomosis in the technically challenging patient, due to anatomic or other reasons, the main key is patience and careful attention to detail. Even in the most difficult setting, satisfactory results can be achieved.
References
1. Dozois R (1990) Ulcerative colitis: surgical alterna- tives. In: Fazio V (ed) Current Therapy in Colon and Rectal Surgery. BC Decker, Toronto
2. Mahid SS, Christmas B, Tran D, Galandiuk S (2006) Triple staple technique for low rectal anastomoses eliminates the purse-string suture and facilitates sta- pled colorectal anastomosis. J Am Coll Surg 202:382- 383
3. Galandiuk S, Scott NA, Dozois RR et al (1990) Ileal pouch-anal anastomosis: reoperation for pouch-relat- ed complications. Ann Surg 212(4):446-454
4. Keighley MRB (1996) Ostomy Management. In: Pem- berton JH (ed) Shackelford’s Surgery of the Alimenta- ry Tract, volume IV: Colon. 5th edn. WB Saunders, Philadelphia
