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Choose your patient

Choose your patient. 42 year old male. 14 year history of ulcerative colitis Steroid dependent Azathioprine Low grade dysplasia. 42 year old male. BMI 34 Hypertension Solicitor. 42 year old male. BMI 34 Hypertension Solicitor Private medical insurance. Choice of operation?.

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Choose your patient

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  1. Choose your patient

  2. 42 year old male • 14 year history of ulcerative colitis • Steroid dependent • Azathioprine • Low grade dysplasia

  3. 42 year old male • BMI 34 • Hypertension • Solicitor

  4. 42 year old male • BMI 34 • Hypertension • Solicitor • Private medical insurance

  5. Choice of operation?

  6. The pouch will not reach

  7. Transillumination

  8. Inadequate reach • Mobilise to pancreas • Divide ileocolic artery • Mesenteric windows • Divide SMA • Consider S pouch

  9. Beware the black pouch • Attention to detail • No twist on the free edge of the small bowel mesentery • Move small bowel to left of abdomen • Check orientation twice – fire gun once

  10. Choice of pouch-anal anastomosis

  11. Double stapled IPAA- operative technique

  12. The staple gun dehisces the stapled anal stump What do you do now?

  13. Hand sewn IPAA

  14. 8 hr post op • P = 120/min • BP = 90/60 mmHg • Low urine output • Pelvic discomfort • PR exam …

  15. Management of post op bleeding from the pouch

  16. Haemorrhage from the pouch or IPAA • Irrigate with a large Foley catheter • If persists – EUA: single point, use diathermy or suture anastomotic defect • If persists – laparotomy & disconnect

  17. 14 hr post op • c/o diffuse swelling of left lower leg • pain on passive stretch of muscles • hyperaesthesia over lateral aspect

  18. Post op day #9 • c/o lower abdominal pain • low grade fever • WCC 18

  19. Pelvic abscess • Initiate therapy immediately • Contained leak or generalised peritonitis? • Establish dependent drainage • Broad spectrum antibiotics • Defer closure of ileostomy

  20. Out patient clinic @ 3 months • c/o • Impotence • Foot drop • Depression

  21. May it please the court…..

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