When the Ileal Pouch Doesn’t Reach

Abstract

Achieving an ileal pouch-anal anastomosis (IPAA) without tension can be difficult in cases where the mesentery doesn’t easily reach the pelvis. Risk factors for inadequate reach are discussed. Maneuvers to gain additional length for the ileal pouch to reach are reviewed, including how to measure for adequate reach, release of small bowel mesentery from the retroperitoneum, duodenal mobilization, mesenteric relaxing incisions, selective ligation or skeletonization of the mesenteric arcade, vascular ligation, intentionally long rectal cuff, shorter efferent limb length, J pouch orientation, and creating an S pouch. When the ileal pouch still won’t reach despite exhaustion of appropriate lengthening maneuvers, “parking” the pouch, conversion to a Kock pouch, and permanent end ileostomy are discussed. Complications related to difficult ileal pouch reach include ischemia and tension on the IPAA.