Surgical challenges of lap pouch surgery
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Surgical challenges of lap pouch surgery
PM SagarThe John Goligher Unit
St James’s University Hospital,Leeds
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Berlin Chirurgical Society 1933
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Kock pouch
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Ileal Pouch-anal Anastomosis
Straight ileoanal anastomosis
Continent ileostomy
Ileal pouch-anal anastomosis
Koch 1969
Nissen 1933
Ravitch & Sabiston 1955
Park & Nicholls 1978
Best1952
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Design of the ileal pouch
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S pouch
• Long efferent spout
• Self intubation in up to 50% of patients
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Difficult reach
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J or W pouch?
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Design of the ileal pouch-anal anastomosis
• Double stapled
• Hand sewn
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Hand sewn IPAA
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Double stapled IPAA
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Laparoscopic Ileal pouch procedure
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Placement of the ports
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Isolation of IMA & V pedicle
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Vascular division
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Left mesenteric division
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Splenic flexure
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Transverse colon
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Hepatic flexure
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Ileocaecal mobilisation
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Right colon
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Ligation of the ileocolic vessels
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Mobilisation of the rectum
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Exposure of the lower rectum
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Mobilisation of the left colon & rectum
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Linear contour to divide at the anorectal junction
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Anorectal division
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The ileal-pouch anal anastomosis
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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
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Pelvic sepsis
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Pelvic sepsis after IPAA (early)
Minor
Anastomotic sinus
EUA + antibiotics
Pouchogram
?Delay closure
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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
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Anastomotic stricture
• Causes – sepsis, tension, ischaemia
• Significant in 5-16%
• More common in stapled vs hand sewn
• Mild / moderate – Rx Hegars dilators
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Transanal pouch advancement
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Transanal pouch advancement
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Transanal pouch advancement
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Pouch advancement
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Pouch-vaginal fistula
Ileal pouch Vagina
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Classification
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MRI - pouch-vaginal fistula
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MR - healed pouch-vaginal fistula
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Transvaginal repair
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Deterioration in pouch function
Pouchitis
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Long efferent spout
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Twisted pouch
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Shrunken pouch
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Mobile blind afferent limb
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Pouch – fallopian tube fistula (Crohn’s disease)
Fistula tract
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Upstream problem:small bowel stricture
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Portal vein thrombosis
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Failed stapling
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Structural causes of pouch dysfunction
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Summary
• Fully counsel your patient
• Attention to detail especially at IPAA
• Structured approach to pouch dysfunction
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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
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Isolation of IMA & V pedicle
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Left common iliac artery
Left ureter
IMA pedicle
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Vascular division
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Left mesenteric division
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Transverse colon
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Ileocaecal mobilisation
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Vascular division
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Exposure of the lower rectum
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Lateral peritoneal reflection
sigmoid
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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”
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Aims of the study
• Safety and long term outcome of cross stapling
• Critical level of the IPAA
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Patients & methods
• Prospective database• July ‘06 - Dec ‘10
• 80 patients underwent IPAA under one surgeon
• Previous STC n=24
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Patients
• J pouch
• All defunctioned
• Steroids < 15 mg /day
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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
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Conclusion
Double stapled IPAA via limited Pfannenstiel incision at lap IPAA
is safe and at an appropriate anastomotic level