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Figures for:
Procedures for Ulcerative Colitis

[ACS Surgery 2004. © 2004 WebMD Inc.
All rights reserved.]


Figure 1. Open proctocolectomy and IPAA. Open proctocolectomy and IPAA. Once the rectum has been dissected down to the level of the pelvic floor, it is divided with a stapler. The stapler is positioned 1 to 2 cm above the dentate line and fired. This positioning ensures that the final pouch-anal anastomosis is within the anal canal and not in the rectum.

Figure 2. Construction of ileal pouch. Open proctocolectomy and IPAA. The ileal pouch is constructed by dividing the common wall of the afferent and efferent limbs of the distal ileum by means of multiple firings of a linear cutting stapler.

Figure 3. Securing of EEA stapler. Open proctocolectomy and IPAA. After the pouch is constructed, the head of an EEA stapler is secured in the apex of the pouch and connected to the pin of the stapler, which was placed upward through the anus.

Figure 4. Completed ileal pouch. Open proctocolectomy and IPAA. Shown is the completed ileal J pouch with the circular stapled anastomosis within the anal canal, just above the dentate line.

Figure 5. Laparoscopic proctocolectomy and IPAA. Laparoscopic proctocolectomy and IPAA. Four trocars are placed in a diamond-shaped pattern: a 12 mm trocar is placed supraumbilically for the camera, another 12 mm trocar is placed in the right lower quadrant, a 5 mm trocar is placed in the left lower quadrant, and another 5 mm trocar is placed above the pubis. A disk of skin and fat is excised for the ileostomy.

Figure 6. Mobilization of the left colon. Laparoscopic proctocolectomy and IPAA. Illustrated is mobilization of the left colon. With the patient in the Trendelenburg position and the left side tilted up, the left lateral peritoneal reflection is opened and the left ureter identified. The descending colon and the sigmoid colon are mobilized medially.

Figure 7. Mobilization of the splenic flexure. Laparoscopic proctocolectomy and IPAA. Illustrated is mobilization of the splenic flexure. With the patient in the reverse Trendelenburg position and the left side tilted up, the splenic flexure is mobilized off the retroperitoneum and the omentum dissected off the distal transverse colon.

Figure 8. Mobilization of the right colon. Laparoscopic proctocolectomy and IPAA. Illustrated is mobilization of the right colon. With the patient in the Trendelenburg position and the right side tilted up, the peritoneum around the cecum and the terminal ileum is scored to enter the correct retroperitoneal plane.

Figure 9. Mobilization of the hepatic flexure. Laparoscopic proctocolectomy and IPAA. Illustrated is mobilization of the hepatic flexure. With the patient in the reverse Trendelenburg position and the right side tilted up, the gastrocolic ligament is elevated.

Figure 10. Mobilization of the rectum. Laparoscopic proctocolectomy and IPAA. Illustrated is mobilization of the rectum. With the patient in the Trendelenburg position and the table tilted neither to the left nor to the right, the left pararectal peritoneum is scored and the presacral space entered.