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Ileal pouch anal anastomosis (IPAA) is the procedure of choice for restorative proctocolectomy. It is most commonly performed in cases of ulcerative colitis (UC) or familial adenomatous polyposis (FAP). In UC, the operation is often done in three stages, where the first operation will be the total abdominal colectomy with end ileostomy in patients who have severe disease, are malnourished, or are on a high dose of steroids or biologics. The second stage is done four to six months after the first operation. This allows the patient to recover from the first operation, regain their nutritional status, and stop the biologics and steroids. The second stage includes proctectomy, with the creation of the IPAA, and creation of the diverting loop ileostomy. The third stage is closure of the loop ileostomy. In this chapter, we describe the second stage of a three-stage pouch surgery, performed laparoscopically.
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PREOPERATIVE CONSIDERATIONS
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In most cases, placement of ureteral stents is not necessary because the rectal inflammation tends to subside after the fecal diversion performed in the first stage. If severe scarring or inflammation is expected, then one must consider bilateral ureteral stents placement. It is particularly useful in patients who may have experienced rectal stump blow-out after their first stage and may have severe pelvic scarring.
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Preoperative Steroids/Biologics
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Steroids are commonly given in an acute flare. However, most patients are not on steroids or biologics during the second-stage surgery and so won’t need stress dosing.
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All these patients have an end ileostomy. The same site can be used for the loop ileostomy. In rare circumstances, the patient may have difficulty with their current ostomy. In these patients, one should have the ostomy nurse mark an ideal location for siting of the loop ileostomy. If necessary, this can be on the left side of the abdomen. It is usually not a problem to bring up the loop ileostomy on either side of the abdomen in these patients.
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It is very important to counsel the patient after their first-stage surgery to avoid gaining weight beyond their ideal body weight. Most of these patients regain their appetite and ability to absorb nutrients after their total colectomy and can easily gain excess weight beyond their presurgery weight or their ideal body weight. Another contributing factor is the advice to eat a low-fiber diet. It is important to explain to the patients that they can eat a regular diet a few weeks after their surgery and to give them a target weight. Patients who are obese will be at a higher risk for postoperative complications and have a higher likelihood of the pouch not reaching the top of the sphincters due to a thicker fat laden mesentery and a ...