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Many 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. In patients with high-grade dysplasia in the rectum, a traditional mucosectomy may be a better option, as it removes all the mucosa. If this technique is done, a hand-sewn ileoanal anastomosis would be required. The J-pouch is constructed by rotating the terminal ileum clockwise to create a “J”-shape (as seen from anteriorly) 15 cm long. The anterior ends are held by semicircular 000 silk sutures (Figure 6). The length is then checked as described above to ensure it will reach the pelvis. The distal antimesenteric end of the pouch is opened with electrocautery. A linear stapler is then inserted and fired, creating a pouch from the two limbs (Figure 7). Multiple firings are used to complete the full length of the pouch (to reach the upper end, the distal end is telescoped onto the stapler). A 2-0 Prolene suture is then used to create a “whip-stitch” purse-string suture around the opening in the tip of the pouch. An anvil of the circular stapler (EEA) is then inserted and the purse-string tied around it (Figure 8). The anvil must sit so that the anti-mesenteric aspect of the ileum is draped across it. The circular stapling (EEA) instrument is then inserted gently into the rectum by an assistant. It is advanced up to the level of the stapled rectal stump. The sharp spike then pierces through the stump at the staple line and it is approximated with the anvil (Figure 9). The device is then closed and fired, taking care not to include adjacent structures such as the vagina. Naive or too-vigorous insertion of the circular stapler (EEA) instrument will rip through the very short rectal stump and make the procedure much more difficult. Figure 10 demonstrates the completed J-pouch with ileorectal stump anastomosis.

If the rectal mucosa is severely diseased, then a complete ...

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