Construction of J-Pouch and S-Pouch

BACKGROUND: Pelvic pouch surgery evolved under the late Dr. Victor Fazio’s influence. OBJECTIVE: To describe construction of J- and S-pouches according to Fazio’s teachings. TECHNICAL POINTS: There are several key points to consider for pelvic pouch construction, starting with the decision of performing a 2- or 3-stage procedure and handling of the rectal stump. At time of pouch construction, ileal reach must be assessed early in the operative course and mesenteric lengthening maneuvers are deployed as warranted. If these maneuvers still do not allow sufficient length, alternatives include an S-pouch, longer rectal stump/anal transition zone, or returning to the operating room at a later date. The rectum is then mobilized sufficiently to allow a straight stapler firing to avoid outlet obstruction from impinged nearby tissues. The 15-20-cm pouch is constructed ensuring its staple lines are straight, staple line bleeding is addressed, the tip of the J is closed to be as short as possible, and a leak test is performed. At the time of the anastomosis, it is crucial to keep the mesentery and pouch straight, ensure no bowel is trapped below the mesentery, confirm that anterior structures are not being incorporated into the anastomosis, and perform a leak test, adding transanal sutures as needed to repair any defects. An ileostomy is then created. CONCLUSION: Pouch construction is challenging. At each stage, consider the patient, who carries the ultimate risk. The end goal is a functional, long-lasting pouch.