V92 - Total proctocolectomy with S-pouch for rectal cancer with Lynch Syndrome

Purpose/Background: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice for patients requiring colectomy who wish to avoid a permanent ileostomy. The J-pouch configuration is most commonly performed; however, S-pouch construction remains a valuable alternative when additional reach to the pelvis is required. This video demonstrates the technical steps and decision-making in performing an S-pouch IPAA in a patient with Lynch syndrome-associated rectal adenocarcinoma.

Methods/Interventions: A 53-year-old man with MSH6- and PMS2-deficient T3aN1 rectal adenocarcinoma and a new diagnosis of Lynch syndrome underwent short-course chemoradiation followed by robot-assisted total proctocolectomy with IPAA and diverting loop ileostomy. During reconstruction, the distal ileum could not reach the anal canal without tension, prompting creation of a three-limbed S-pouch. The pouch was constructed using two side-to-side enteric anastomoses with running 3-0 Vicryl and 3-0 PDS sutures to form a 12-cm reservoir. The pouch was oriented and delivered transanally for a hand-sewn pouch-anal anastomosis following mucosectomy.

Results/Outcomes: Final pathology revealed T1N0 disease with negative margins and extensive treatment effect. The pouch appeared well perfused with appropriate orientation and tension-free anastomosis. The patient recovered uneventfully and was discharged on postoperative day 7. His gastrografin enema was negative for pouch leak and he subsequently underwent ileostomy reversal at 3 months with good pouch function and continence.

Conclusion/Discussion: This case highlights the utility of the S-pouch configuration when additional reach is required to achieve a tension-free anastomosis in restorative proctocolectomy. Although technically more complex than the J-pouch, the S-pouch remains an important tool in the colorectal surgeon's armamentarium, particularly in tall patients or those with a deep pelvis. Mastery of its construction allows for safe reconstruction when standard pouch configurations are not feasible.

S-pouch incision
Planning the S-pouch enterotomy, ensuring the incision on the outer limbs is close to the inner limb to allow for the largest possible pouch size.