Oncology Patients With
Cylinders for Intracavitary
of Uterine Afterloading Applicators
for Intracavitary Radiation Therapy
Injection of Chromic Phosphate
Omental Pedicle "J"
With Bilateral Inguinal
Lymph Node Dissection
Vulva With Gracilis Myocutaneous Flaps
Flap and Vertical Rectus
Bilateral Pelvic Lymph
Node Dissection and With Extension of the Vagina
"J" Pouch Rectal
Omental "J" Flap
Continent Urostomy (Miami Pouch)
Gracilis Dynamic Anal
System Versus Skin Grafting
Pelvic Flap for
Augmentation of Continent Urostomy or Neovagina
of Hemorrhage in Gynecologic Surgery
of the Punctured
of a Lacerated
Internal Iliac Vein and
Suturing of a Lacerated Common Iliac Artery
Suspension of the Vagina
Not to Do in Case of Pelvic Hemorrhage
Associated With Abdominal Pregnancy
"J" Pouch Rectal Reservoir
When the rectosigmoid colon must be removed in the treatment of genital
cancer, an end sigmoid colostomy or a very low coloproctostomy may
be performed. Very low anastomosis of the colon to the rectum may be
associated with an unacceptable frequency of daily bowel movements.
Although it is a social and esthetic relief to the patient to eliminate
the colostomy stoma, having 6-8 bowel movements per day is an inconvenience
and hardship. Treatment of the problem with opiates may produce addiction.
purpose of the "J" colonic pouch is to provide a rectal reservoir,
thereby reducing the number of bowel movements and eliminating the
need for drugs.
Physiologic Changes. The "J" pouch
rectal reservoir provides an increased storage area for feces. This
may precipitate fluid absorption from the fecal stream and result in
a firm but soft stool. The patient experiences a reduction in tenesmus.
Points of Caution. Adequate mobilization of the transverse
and descending colon must be performed to allow the end-to-side Strasbourg-Baker
anastomosis to be performed without tension. Since many of the patients
undergoing this procedure have had pelvic irradiation, it is important
to keep the inferior mesenteric artery and its superior hemorrhoidal
branch intact if possible. These arteries will supply blood to the
anastomosis, thereby aiding the wound healing process and reducing
suture line leaks and fistulae.
Although it is possible to perform
this procedure with a suture technique the use of surgical staplers
reduces tissue trauma, allows precise placement of sutures, and significantly
reduces operative time.
If the patient has had pelvic irradiation or
inflammatory bowel disease, a temporary diverting colostomy should
be performed and kept in place until complete wound healing has been
demonstrated. This is usually accomplished within 8 weeks.
The descending colon is adequately
mobilized, and an appropriate site is selected for the side-to-end
Strasbourg-Baker coloproctostomy. This site should be at the
midpoint of at least 20 cm of distal colon. It should allow 10
cm of colon for the down side of the "J" pouch and 10 cm for
the up side.
A stab wound is created at the
midpoint lateral to the antimesenteric border. The gastrointestinal
anastomosis (GIA) surgical stapler is inserted. The mesentery
is cleared from the stapler, and the GIA instrument is fired.
This establishes the distal 5 cm of the pouch.
Frequently, it is difficult to reapply the
GIA stapler from below for the second 5-cm portion of the pouch.
Therefore, it is more convenient to open two small stab wounds
on each segment of the J pouch from above and insert each blade
of the GIA, connecting them so that they will match the procedure
The surgeon can easily close
the opening from the stab wound by picking up the margins of
the wound with Allis clamps, placing a TA-55 (4.8 mm) stapler
across the wound, and activating the stapler.
A pursestring suture of 2-0 nylon is placed
around the enterotomy at the midpoint at the bottom of the J
A pursestring suture of 2-0
nylon is placed around the margins of the rectal stump.
The EEA (end-to-end anastomosis) stapler is inserted through the anus. After
opening the stapler, the surgeon ties both pursestring sutures around the central
rod of the stapler. The EEA stapler is closed, then activated, and the coloproctostomy
anastomosis is completed.
This cutaway view shows the
completed J pouch rectal reservoir.