VA105 - Ileal Pouch Volvulus: Laparoscopic detorsion and pouchpexy

Purpose/Background: Pouch volvulus is a rare but reported complication following total proctocolectomy and ileal pouch-anal anastomosis. Prompt management is critical to rescue the pouch and prevent recurrence as delayed intervention can lead to pouch ischemia and the need for excision.

Methods/Interventions: We present a case of a 23-year-old male who had had multiple ED trips for abdominal pain and distension due to an unrecognized pouch volvulus. Upon identifying the volvulus, endoscopic detorsion was attempted but was unsuccessful. The patient then underwent urgent laparoscopic detorsion and pouchpexy. The pexy was performed with a running 3-0 V-loc and multiple interrupted 3-0 Ethibond sutures all anchoring the posterior mesentery to the presacral fascia.

Results/Outcomes: The patient recovered well and was discharged three days post-surgery with good pouch function and resolution of obstructive symptoms.

Conclusion/Discussion: Prompt recognition of pouch volvulus is essential as early intervention can facilitate minimally invasive detorsion and pouchpexy. Additional intraoperative considerations include pexy sutures to the lateral pelvic sidewall particular in cases where the mesentery is positioned anteriorly, pexy of the afferent limb should this be the lead point of the volvulus, and the possible use of mesh to anchor the pouch and obliterate the space underneath the mesentery.