In this view the descending colon, cecum, and terminal ileum, note that the avascular plane of Treves has been entered after the terminal ileum was divided. The incision in the avascular plane of Treves was carried lateral to the ileocolic artery and medial to the superior mesenteric artery. The blood supply of the entire Kock pouch depends on the superior mesenteric artery and its branches. A 5-cm plug of ileum with its mesentery is removed at the upper limit of the Kock pouch to allow placement of the efferent limb of bowel at the preferred stoma site. The first 17-cm segment of the pouch is marked off and labeled for the efferent limb of bowel and the efferent nipple. The next 22-cm segment comprises one loop of the U-shaped pouch, and the last 22-cm segment forms the other limb of the U-shaped loop of the pouch. The last 17-cm segment is available for the afferent nipple and bowel limb of the pouch. This segment is not necessary if the surgeon is converting an ileal loop to the pouch.

The two 22-cm U-shaped limbs are placed adjacent to each other, and interrupted 3-0 polyglycolic acid (PGA) sutures are placed in the bowel 1 cm above the junction of the two segments. A cautery is used to open the intestine approximately 2 cm from the junction of the mesentery, as indicated by the dotted line. This opening is extended on the efferent and afferent limbs for a distance of approximately 5 cm; the cautery electrocoagulates the small blood vessels on the edge of the bowel.

A 3-0 PGA suture on a straight fine intestinal needle runs through the back wall of the pouch. A second layer of 3-0 PGA sutures is placed between these sutures.

Construction of the nipples in the afferent and efferent limbs has begun. An 8-cm opening is created in the mesentery by opening the windows of Deaver, applying Hendren's rule that 4 cm of mesentery adjacent to the small bowel can be undercut because there is enough lateral vasculature in the small bowel wall to prevent necrosis. An opening of 8 cm is essential for nontraumatic intussusception and to prevent "extussusception," i.e., undoing of the intussusception. A Babcock clamp is inserted into the lumen of the bowel, and a small Kelly clamp is used to indent the bowel wall into the Babcock clamp.

Papaverine, 300 mg in 500 mL of normal saline, must be administered intravenously 10-15 minutes before intussusception for smooth muscle relaxation to allow intussusception without trauma to the small bowel. A slight drop in the patient's blood pressure should be expected; this rarely exceeds 20 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure.

A 2-cm strip of PGA mesh is passed through the window of Deaver. This will be sutured in place after the nipple has been created.

The intussusception is being performed under the influence of a smooth muscle relaxant. A segment of bowel is pulled out for a distance of 6-7 cm.

The TA-55 4.8-mm stapler with 5 staples missing from the heel of the stapler is inserted on the nipple and stapled at the 2 and 10 o'clock positions.

The nipple is stapled to itself twice, at the 10 and 2 o'clock positions, with the S-GIA URO stapler (United States Surgical Corp.). The stapler contains no blade, and the inner rows of staples have been removed. It has the advantage of having no pinhole.

An alternative method would be to perform a small enterotomy in the posterior wall of the pouch; place the stapler through the enterotomy and then through the nipple, and staple it. All pinholes from the TA-55 stapler must be sutured with interrupted 3-0 PGA sutures before proceeding. Note that the PGA mesh in the window of Deaver is still not sutured in place.

Both afferent and efferent nipples have been completed. Note that the two strips of PGA mesh pass through the windows of Deaver in the mesentery of both the efferent and afferent bowel limbs adjacent to the nipples. The letters A to A', B to B', and C to C' delineate the order of suture placement that will produce a spherical rather than a tubular pouch.

With the pouch still open, the No. 30 French Medena catheter is inserted up the nipple in a retrograde fashion to allow accurate sizing for the PGA mesh. The mesh is sutured with interrupted 3-0 PGA sutures in a fashion that securely locks it at the junction of the intussusception to prevent extussusception.

The pouch is closed with 3-0 PGA sutures by approximating points A to A', B to B', and C to C'.

The remaining walls of the pouch are sutured with a running 3-0 PGA suture, and a second layer of running 3-0 PGA sutures is added.

In the completed pouch, the PGA mesh is in place adjacent to the intussusception. Two enterotomies have been made in the afferent limb of the bowel. Two No. 8 French Finney J Silastic catheters are threaded through the enterotomies, down the afferent limb, through the afferent nipple, and into the pouch. The ureters previously mobilized have been spliced by incising the ureteral wall for a distance of approximately 3 cm.

The Finney J Silastic catheter has been threaded up the ureters and into the renal pelvis. The ureter has been sutured to the enterotomy in the bowel with interrupted 4-0 PGA sutures in a mucosa-to-mucosa technique. Additional sutures are placed between the serosa of the bowel and the ureter. Indigo carmine dye, 3 mL, is administered intravenously. The suture line is thoroughly inspected to ensure that there is no leakage of blue dye-stained urine coming from the kidney and down the ureter. Note that the Finney J Silastic catheters are threaded into a loop. The J curled ends of the catheters indicate they are within the pouch and not in the nipple.

The efferent bowel limb has been exteriorized through an umbilical ostomy defect. In addition, the efferent bowel limb has been tapered to fit a No. 20 French Medena catheter with the GIA instrument. Both of these procedures, exteriorization through the umbilicus and the tapering of the efferent bowel limb, are designed to reduce the diameter of the efferent bowel limb and therefore raise the pressure of the overall efferent system to greatly exceed that in the pouch.

The efferent port is sutured on its medial and lateral borders to the anterior rectus fascia.

The tapered efferent bowel limb is brought through the ostomy defect in the umbilicus. The sutures are tied to the umbilical ostomy defect.

The efferent tapered nipple bowel limb is sutured to the edge of the umbilical defect.

A No. 20 French Medena catheter is inserted through the efferent bowel limb through the efferent nipple into the pouch. The stoma has been matured in the umbilicus. The afferent bowel limb containing the ureters and the afferent nipple are shown on the right. Note the J Silastic stents coming from the renal pelvis down the ureters through the afferent bowel limb through the afferent nipple into the pouch. These are removed with a cystoscope 3 weeks following surgery.

The very important Jackson-Pratt suction drainage shown on the right remains in place until the pouch has completely healed and there is no leakage from the pouch or any of the anastomoses. This Jackson-Pratt drain is usually removed 3 weeks postoperatively.