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Malignant Disease:
Special Procedures

Staging of Gynecologic
Oncology Patients With
Exploratory Laparotomy

Subclavian Port-A-Cath 

Peritoneal Port-A-Cath

Application of Vaginal
Cylinders for Intracavitary
Radiation Therapy

Application of Uterine Afterloading Applicators
for Intracavitary Radiation Therapy  

Pelvic High-Dose Afterloader

Abdominal Injection of Chromic Phosphate

Supracolic Total Omentectomy

Omental Pedicle "J" Flap

Tube Gastrostomy

Total Vaginectomy

Radical Vulvectomy
With Bilateral Inguinal
Lymph Node Dissection

Reconstruction of the
Vulva With Gracilis Myocutaneous Flaps

Transverse Rectus
Abdominis Myocutaneous
Flap and Vertical Rectus
Abdominis Myocutaneous

Radical Wertheim
Hysterectomy With
Bilateral Pelvic Lymph
Node Dissection and With Extension of the Vagina

Anterior Exenteration

Posterior Exenteration

Total Pelvic Exenteration

Colonic "J" Pouch Rectal

Kock Pouch Continent Urostomy

Omental "J" Flap Neovagina

Ileocolic Continent Urostomy (Miami Pouch)

Construction of Neoanus
Gracilis Dynamic Anal

Skin-Stretching System Versus Skin Grafting

Gastric Pelvic Flap for
Augmentation of Continent Urostomy or Neovagina

Control of Hemorrhage in Gynecologic Surgery

Repair of the Punctured
Vena Cava

Ligation of a Lacerated
Internal Iliac Vein and
Suturing of a Lacerated Common Iliac Artery

Hemorrhage Control in
Sacrospinous Ligament
Suspension of the Vagina

Presacral Space
Hemorrhage Control

What Not to Do in Case of Pelvic Hemorrhage

Packing for Hemorrhage

Control of Hemorrhage
Associated With Abdominal Pregnancy

Colonic "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.

The 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 from below.

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 pouch.

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.

Copyright - all rights reserved / Clifford R. Wheeless, Jr., M.D. and Marcella L. Roenneburg, M.D.
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