Laparoscopic Abdominoperineal Pouch Excision (Video)

Pouch excision may become necessary due to pelvic sepsis, poor function, dysplasia, malignancy and other indications.

In this video, you’ll see highlights of a laparoscopic abdominoperineal pouch excision followed by the construction of an ileostomy.

Steven Wexner, MD, Director of the Digestive Disease Center and Chair of Colorectal Surgery at Cleveland Clinic Florida, explains the procedure step by step and offers guidance on:

1. Proper port placement
2. Why it’s important to mobilize the small bowel
3. Pelvic dissection of the pouch
4. Perineal intersphincteric dissection and transanal delivery of the pouch
5. Closure of the perineum
6. Construction of the stoma

In this patient, the port placement is in the left upper quadrant, left lower quadrant and ultimately near the incision, but only after beginning with a midline incision with a Hasson technique, a safe site remote from any incision. The video shows lysis of adhesions in order to mobilize the small bowel to ensure adequate reach for ileostomy and absence of Crohn’s disease.

The surgeon then attends to the pelvis, identifying and beginning to mobilize the J pouch. He uses a 5 mm ultrasonic scalpel and 10 mm diameter noncrushing forceps to perform the dissection.

“The constant plane should be the plane over the sacral promontory posterior to the pouch,” notes Dr. Wexner. “Especially if the mesentery is posterior and the pouch is anterior, it’s a fairly straightforward plane… so what I try to do is get under the pouch at the promontory to try and isolate the efferent limb and perhaps divide the mesentery to the efferent limb so that the pouch is suspended and we can continue dissecting behind it.”

Watch as Dr. Wexner continues the surgery with perineal intersphincteric dissection and transanal pouch delivery and finishes with closure of the perineum and construction of the stoma.