VM72 - Small Bowel Retroperitoneal Mobilization in 3-Stage Laparoscopic Ileal Pouch-Anal Anastomosis

Purpose/Background: Aptitude in performing ileal pouch-anal anastomosis is critical for every training colorectal surgeon. Publicly available educational videos demonstrating the procedure are 2-stage ileal pouch-anal anastmosis with unperturbed plains. However, there are many benefits to 3-stage procedures. We sought to demonstrate a guided dissection of a critical mesenteric lengthening maneuver which is unique to a 3-stage approach.

Methods/Interventions: We present a representative video of a patient with ulcerative colitis following total colectomy undergoing stage 2 of laparoscopic ileal pouch-anal anastomosis. Our technique is via single port laparoscopy. We focus specifically on the small bowel laparoscopic mobilization.

Results/Outcomes: The guided steps of this are:
1. Ileostomy takedown, insertion of a gelport through the ileostomy site. We use a 12mm trocar (camera) and two 5mm trocars (LigaSure and grasper).
2. Dissection proceeds posterior to the small bowel mesentery, separating it from the retroperitoneum, and proceeding medially towards the inferior border of the duodenum.
3. Identification and isolation of the ileocolic branch of the SMA.
4. Having reached the vascular pedicle at the third portion of the duodenum, the dissection changes direction. We begin cephalad mobilization of the vascular pedicle to maximize mesenteric length.
5. The dissection is complete once the vascular pedicle has been adequate skeletonized over the duodenum.

Conclusion/Discussion: This is a valuable, unique educational video which realistically guides training colorectal surgeons towards a nuanced dissection of retroperitoneal mobilization to enhance mesenteric length.