Ileal pouch-anal anastomosis surgery: Surgical techniques

Surgery has an incidence of 20–30 % among patients affected by Ulcerative Colitis (UC) and its goal is the total removal of the large bowel. There are several indications for surgery in UC patients, in elective, urgent, or emergency conditions. On the basis of patient history and presentation, different procedures, with different timing, should be performed, such as total proctocolectomy and permanent ileostomy or Koch’s pouch, ileo-rectal anastomosis, or total proctocolectomy with ileo-pouch-anal anastomosis (IPAA). Nowadays, the procedure of choice is the IPAA, as advocated by Parks and Nicholls 35 years ago. Despite considerable improvement in medical treatment and surgical technology, the procedure remains basically the same highly demanding operation, with a low mortality rate in elective settings, but with a consistent morbidity. IPAA is a very complex procedure, based on an extended colorectal resection, and an autologous transplantation to create a new rectum using the small bowel, but it is also a “quality of life” surgery. Today, the best way to perform this intervention is the laparoscopic approach. When IPAA fails, for septic or mechanical problems, a redo pouch should be performed with good results. However, for all these reasons, it is strongly recommended that IPAA should be performed only in tertiary referral Centres by dedicated colorectal surgeons.