mainz ii surgery illustrated

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2 0 1 0 T H E A U T H O R S1 8 3 0 B J U I N T E R N A T I O N A L 20 10 BJ U IN TE RN AT IO NA L | 10 6, 18 30 1 85 4 | doi:10.1111/j .1464-410X.2010.09773.x

Surgery Illustrated Surgical Atlas

Mainz pouch continent cutaneous diversion

Joachim W. Throff, Hubertus Riedmiller*, Margit Fisch

, Raimund Stein,Christian Hampel and Rudolf Hohenfellner

Department of Urology, University Medical Center, Johannes Gutenberg University, Mainz; *Department of Urology

and Paediatric Urology, University Hospital Wrzburg, Wrzburg,

Department of Urology, University Medical Center

Hamburg-Eppendorf, Hamburg, Germany

ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com

INTRODUCTION

Since the early 1980s, the ileocaecal segmenthas been used in the Mainz pouch technique

not only for continent cutaneous urinarydiversion but also for orthotopic bladdersubstitution [14]. Initially, the ileal

intussusception nipple was the standardcontinence mechanism for the catheterizable

efferent segment [13]. Since 1990, thesubmucosally embedded appendix, whenavailable and useable, has become the

standard catheterizable continent efferentsegment [5] and the intussusceptionnipple remains a reserve technique after

appendectomy. Both techniques are describedin this article. Other catheterizable continentconduits have been developed [6] but are not

described herein. The Mainz pouch offers alow-pressure reservoir with good capacity [7].To date, >

1500 procedures have been

performed at our institution.

PLANNING AND PREPARATION

INDICATIONS

The main indication for continent cutaneousdiversion by the Mainz pouch technique is

bladder cancer, when orthotopic bladdersubstitution after radical cystoprostatectomy(cystectomy in females) is not the patients

choice or not advisable. The latter is the case ifurothelial cancer extends into the prostate (infemales beyond the bladder neck), or if in

frozen sections the surgical margins arepositive for cancer, so that urethrectomy isrequired. In other cases, pre-existing

sphinteric urinary incontinence (e.g. after

ET AL

.

a

b

a

b

BJUI

B J U I N T E R N A T I O N A L

1012cm1012cm

Appendix-Stoma

1012cm


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S U R G E R Y I L L U S T R A T E D

radical prostatectomy) would makeorthotopic bladder substitution unlikely to be

functional. Females after orthotopic bladdersubstitution require in up to one third of casesintermittent catheterization for neobladder

emptying. Some of them prefer continentcutaneous urinary diversion for the ease ofcatheterization through the umbilicus rather

than through the urethra. Other indicationsare benign conditions with and withouturinary incontinence, such as hyperreflexive

neurogenic bladder or interstitial cystitis,when urinary diversion is required or is thepatients wish.

Patient selection is critical for the functionalsuccess of the procedure. In patients aged

>

75 years or in patients with a lack ofmotivation or manual dexterity (hemiplegics,

tetraplegics) to perform transumbilical cleanintermittent self-catheterization (CISC), anincontinent type of urinary diversion might bepreferable.

SPECIFIC INSTRUMENTS AND MATERIALS

Optical loupes (

2.53.5, 50 cm focallength) Headlight

Allis clamps 4/0 glyconate monofilament absorbable

sutures on a 1/2 needle (HR22) forileoascendostomy, pouch suturing 4/0 polydioxanone monofilament

absorbable sutures on a straight 60 mmneedle for pouch suturing 4/0 polyglytone monofilament rapidly

absorbable sutures on a 1/2 needle (CV-23)for fixation of stents, pouchostomy 4/0 polypropylene monofilament

nonabsorbable sutures on a 1/2 needle (RB-1)

for closing the caecal seromuscularis over theembedded appendix

3/0 polypropylene monofilamentnonabsorbable sutures on a 1/2 needle (RB-1)for securing the base of the intussusception

nipple and for fixation of the pouch againstthe abdominal peritoneum 2/0 polyglactin braided absorbable sutures

on a 3/8 needle (UR-6) for fixation of theafferent segment to the abdominal fascia 4/0 polydioxanone monofilament

uncoloured absorbable sutures on a cutting3/8 needle (FS-2S) for anastomosis of theefferent segment with the umbilical skin

6/0 and 5/0 glyconate monofilamentabsorbable sutures on a 1/2 needle (HR13) forureteric anastomosis

6 F and 8 F polyurethane/polypropyleneureteric stents

10 F pigtail pouchostomy catheter TA 55 stapler with 4.8 mm metal staples(green magazine)

To exclude a pathology of the bowel segmentsrequired for pouch formation, preoperativeevaluation must include imaging of the colon

by conventional retrograde double-contrastcolonography, colonoscopy or preferably CT-colonography. Colonic diverticulae are rare in

the caecum and ascending colon and, ifpresent, are not a contraindication to performthe procedure. However, polyps should be

removed preoperatively by colonoscopy toobtain a histological diagnosis.

The day before surgery the bowel is cleansedby administering 3 L of polyethylene glycolsolution. During surgery antibiotics

(ampillicin/clavulanic acid and metronidazol)are administered and continued for 710days.

The patient is placed supine on the table withabout 15

of overextension.

INTRAOPERATIVE DECISION MAKING

APPENDIX STOMA OR INTUSSUSCEPTIONNIPPLE?

In general, an appendix stoma would be thefirst choice, if the appendix is of normal size

and calibre. However, even if the appendixlooks normal, this should be checked as a firststep by appendiceal calibration and dilatation

(Fig. 2) before decisions about length of bowelresection for pouch formation are made(Figs 3 and 11). The reason is that a normal

looking appendix might (rarely) revealobliteration upon calibration.

Moreover, patients have to be informedpreoperatively, that an appendix stoma hasexcellent continence results but higher rates

of stoma stenosis due to its smaller calibre ascompared with an ileal intussusceptionnipple. If an appendix stoma is possible and

reflects the patients wish, bowel resectioncan be started and requires only resection of2025 cm of terminal ileum (Fig. 3). If the

appendix is not useable as the continencemechanism, is absent, or if it is the patientswish, an ileal intussusception valve is an

alternative continence mechanism. However,it requires 12 more centimetres of ileumresection (Fig. 11). The proximal 12 cm of

ileum required for creation of theintussusception nipple must remain intactwhen all the other bowel segments are

opened antimesenterically for sphericalreconfiguration and pouch formation(Fig. 12).


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Figure 1

A midline abdominal incision is made withleft-sided semi-circumcision of the umbilicus.The length of the abdominal incision depends

on whether continent urinary diversion isperformed with or without cystectomy (e.g. inneurogenic bladder). In any case, it should

allow complete mobilization of the right colonbeyond the right colonic flexure.


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Figure 2

If an appendix of normal size and length ispresent, its usability as a continent outletshould be determined before any decisions on

the length of bowel resection are made. Forthis, the appendix is opened at its tip,calibrated and stepwise dilated with metal

sounds of increasing diameter. Dilatationshould allow insertion of at least a 16 Fcatheter in adults and a 14 F catheter in

children. If the appendix is too narrow toaccommodate catheters of a reasonable size,emptying of the pouch may be cumbersome

due to a low flow and plugging of thecatheter by mucous. If this is the case, theappendix should rather be resected and an

ileum intussusception nipple (Fig. 11ff) beconsidered as continent outlet.

a

b


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Figure 3

Caecum and ascending colon are mobilizedbeyond the right colonic flexure from theright abdominal wall. For an ileocaecal pouch

with appendix stoma, 1012 cm of caecumand ascending colon and 2025 cm of distalileum are marked by stay sutures at the

intended resection lines. The mesentery of theascending colon is divided between the rightcolonic and the ileocolic arteries, where

usually only one vascular arcade close to thebowel has to be transected. The mesentery ofthe ileum is divided using the back-light

technique for identification of the vascularsupply. In this technique, a focal light (e.g.fibre optic cold light) is directed onto the

mesentery at the opposite side of thesurgeons view for transillumination so that,

with the room lights dimmed, the vessels inthe mesentery can be seen. Usually two to amaximum of three vascular arcades have tobe divided.

For additional intraoperative cleansing of theisolated ileocaecal segments, a 20 F Foley

balloon catheter is inserted proximally intothe ileum and secured, and the bowel

segments are rinsed with saline using a bowelsucker in the ascending colon for removingthe fluid. With a 100-mL syringe, these

segments are rinsed repeatedly until theoutflow becomes clear.

10 12 cm10 12 cm

Appendix-Stoma

10 12 cm


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Figure 4

After the proximal end of ileum and thedistal end of ascending colon have beenmechanically cleaned by using several

gauze swabs, bowel continuity is restored.Ileoascendostomy is accomplished instandard technique as a sutured single-row,

dual-layer (seromuscularis), running end-to-end anastomosis. For adjustment ofdifferences in bowel diameter, the ileum is

spatulated antimesenterically. For the runningbowel sutures of the posterior and anteriorwalls, 4/0 polyglyconate monofilament

absorbable sutures are used. The same suturematerial is used to close the mesenteric gapwith another running suture.

a

b


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Figure 5

For spherical reconfiguration of the bowelsegments into the pouch, ileum andascending colon are split open at their

antimesenteric borders (dotted line), but thecaecum must remain intact to create thecontinence mechanism, which requires

embedding of the appendix into the anteriortaenia.


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Figure 6

The posterior wall of the pouch is establishedby side-to-side anastomosis of the ascendingcolon with the terminal ileal loop and of the

latter with the next proximal ileal loop. Theanastomoses are made by single-row, all-layer running sutures of 4/0 polydioxanone

monofilament absorbable sutures on astraight needle. The straight needle allowsfaster hand suturing than a curved needle

with a needle holder. However, each of thelong running sutures should at least beinterrupted once in half of the suture line.


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Figure 7

Antirefluxive ureteric implantation bycreating a 34 cm submucosal tunnel isperformed in the open end technique, in

which the submucosal tunnel is establishedfrom the margin of the transected ascendingcolon. For establishing the tunnel, two stay

sutures must be placed on either side of thetunnel. The tunnel is established by dividingthe mucosa from the muscularis with scissors

by sharp and blunt dissection, starting fromthe margin of the transected ascending colon(

A

). This procedure is eased if the bowel is

stretched well between the stay sutures and ifthe tunnel is established along one of thelongitudinal taeniae rather than at the

haustra. If the mobilization of the mucosa isdifficult, previous submucosal injection of

saline along the intended tunnel length ishelpful to separate mucosa from muscularis.

The ureter is spatulated ventrally over 2

3 mm and should be freed from excessiveconnective tissue outside its vascular supplylayer over the tunnel length. On a stay suture,

the ureter is pulled with a curved clamp intothe tunnel (

B

).

The ureteric orifice is anchored at itsdistal end by a 5/0 glyconate absorbable

monofilament suture through theseromuscularis and mucosa of the bowel.The neo-orifice of the spatulated ureter is

completed by 6/0 polyglyconate absorbablemonofilament uretero-mucosal sutures (

C

). Atthe entrance of the ureter into the tunnel,

the ureter is anchored by another 6/0polyglyconate suture between seromuscularisof the bowel and adventitia of the ureter.

a

b

c


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Figure 8

The left ureter is brought into the rightretroperitoneum behind the mesentery of thedescending colon and in front of the large

abdominal vessels. This should beaccomplished above the inferior mesentericartery to avoid compression of the ureter

between the inferior mesenteric artery andthe aorta (ureteric nutcracker phenomenon).The ureters are intubated with 6 F stents (8 F

stents for dilated ureters), which are securedto the mucosa by 4/0 polyglytone rapidlyabsorbable monofilament sutures and

brought out on the right side through thebowel wall where they are secured again withthe same rapidly absorbable sutures. For

creation of the continence mechanism of theappendix, a submucosal tunnel at the lower

caecal pole is established for embedding theappendix. The seromuscularis of the anteriortaenia of the lower caecal pole is incised downto the mucosa over a length of

5 cm. If

during this preparation, the mucosa isinadvertently damaged, the hole may beclosed by a 6/0 polyglyconate absorbable

monofilament suture without expecting anyproblems from this.

For preserving the blood supply to theappendix, incisions of the serosa (dotted lines)

between the perpendicular vessels of thelowest arcade of the appendicular artery areperformed using the back-light technique to

create openings in the mesenteriolum.


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Figure 9

A

, shows the completed caecal mucosal bedafter longitudinal splitting of the anteriortaenia down to the mucosa for submucosal

embedding of the appendix. Furthermore, thewindows in the mesenteriolum between theperpendicular blood supply are seen. B

, the

appendix is intubated with the Foley ballooncatheter for pouch drainage and flipped overinto the submucosal bed. The seromuscularis

of the caecal pole is closed through thewindows in the mesenteriolum by several 4/0polypropylene nonabsorbable monofilament

sutures.

a

b


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Figure 10

The pouch has been completed by closing theanterior wings of the pouch plate with severalrunning 4/0 polydioxanone monofilament

absorbable sutures. Note single interruptedsutures at the entrance of the ureters intotheir respective submucosal tunnels to

prevent compression of the ureters at thesesites. In addition to the two ureteric stents,which had been brought out through the

right lateral pouch wall, a 10 F pigtailpouchostomy drainage is brought outthrough the pouch wall and secured with a

4/0 polyglytone rapidly absorbablemonofilament suture.


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Figure 11

If the appendix is not useable as thecontinence mechanism or absent and anileum intussusception nipple is to be

constructed, bowel resection has to comprise12 more centimetres of ileum proximally forconstructing the intussusception nipple.

12 cm10 12 cm10 12 cm

10 12 cm

Ileum-Intussusception Nipple


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Figure 12

The ileoascendostomy for reconstitution ofbowel continuity has been completed, theascending colon and the terminal to ileal

loops have been opened for spherical pouchreconfiguration and the posterior wall of thepouch has been established by side-to-side

anastomoses. Note that the proximal 12 cmof ileum in continuity to the pouch remainunopened for construction of the

intussusception nipple. The mesentery of theproximal intact ileal segment is beyond thefirst arcade divided from the ileum over a

distance of 5 cm to ease the intussusception.


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Figure 13

A

, shows the dimensions of the segmentsused for the intussusception nipple. Thelength of the mesenterial exclusion is 5 cm

over the tip of the nipple. B will be the tip ofthe nipple, AB will be the outer layer and BC the inner layer of the nipple. The proximal

2 cm are for anastomosis with the umbilicus.

B

, two Allis clamps have been insertedthrough the ileocaecal valve into the proximal

segment of ileum and have grasped the ilealwall at opposite sides of B for establishing theisoperistaltic intussusception nipple.

5 cm

2 cm

a

A B C

b

5 cm

5 cm


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Figure 14

The isoperistaltic intussusception nipple of5 cm is completed and pulled by two Allisclamps through the ileocaecal valve.


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Figure 15

The ileal intussusception nipple is stabilizedand fixed to the ileocaecal valve by three rowsof staples, two rows of which are applied from

inside the pouch and one further fromoutside.

For the two staple rows applied from insidethe pouch, three staples, which would belocated at the tip of the nipple but are not

required for nipple stabilization and fixation,are removed from the magazine to avoidexposure of these staples to urine and

encrustation (

A

). For this, a TA55 magazinewith 4.8 mm staples (green magazine) isinserted only three-quarters into the

magazine holder to allow asymmetricalclosure. With the magazine closed at this

position, the release handle is slowly andgradually advanced only so far, so that themost inner staples would appear at this modeof asymmetrical release. This allows removal

of some of the staples at the inner part of themagazine, which later on would be at the tipof the nipple, without advancing all the other

staples of the magazine.

However, before application to the nipple themagazine is now completely inserted into themagazine holder and inserted into the nipple

within the ileocaecal valve (

B

). The magazineis closed, its position and the correctalignment of the pin at the tip of the

magazine are checked and it is released. Asthe magazine staples three layers of bowel(two layers of intussusception valve and the

ileocaecal valve), there is crushing of themucosa, which is of no concern. Moreover, thethree-layer stapling process produces deep

insertion of the staples with later healing ofthe crushed mucosa over the metal staples, soideally no metal staples will be exposed to

urine when healed. The pin of the magazine,necessary for exact alignment of the staples,produces a pinhole at the base of the nipple

through all bowel layers, which must beclosed to avoid a fistula at this site.

a

b


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Figure 16

A,

shows the closure of the pinhole from thefirst stapler application by a 4/0 polyglyconateabsorbable monofilament suture in a figure-

of-eight fashion. Furthermore, the secondrow of staples is applied in an identical way asthe first one in Fig. 15.

B,

shows the closure of the pinhole from thesecond stapler application by a figure-of-

eight 4/0 polyglyconate absorbablemonofilament suture. Furthermore, the thirdstapler application from the outside of the

pouch is shown. For this application, nostaples must be removed from the magazine.The stapler is inserted into the serosal slit

between the inner and outer layer of thenipple and slit down to the tip of the nipple.

Thus, it encompasses only two layers: theouter layer of the nipple and the lower pouchwall with the ileocaecal valve. This row ofstaples attaches the nipple to the wall of the

pouch to prevent dislodgement of the nipplefrom its intended position (nipple sliding).

a

b


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Figure 17

A

, shows the closure of the pinhole from thethird stapler application for fixation of thenipple to the pouch wall by a figure-of-eight

4/0 polyglyconate absorbable monofilamentsuture. Furthermore, the tip of the nipple issecured to the ileocaecal valve by several 4/0

polyglyconate absorbable monofilamentsutures.

B

, the mesenterial slit of the intussusceptionnipple is closed by several 3/0 polypropylenenonabsorbable monofilament sutures.

a

b


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Figure 18

The pouch has been completed by closing theanterior wings of the pouch plate with severalrunning 4/0 polydioxanone monofilament

absorbable sutures. Note the singleinterrupted sutures at the entrance of theureters into their respective submucosal

tunnels to prevent compression of the uretersat these sites. In addition to the two uretericstents, which had been brought out through

the right lateral pouch wall, a 10 F pigtailpouchostomy drainage is brought outthrough the pouch wall and secured with

a 4/0 polyglytone rapidly absorbablemonofilament suture.


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Figure 19

For the creation of the umbilical stoma, theskin funnel of the umbilicus is separated fromthe abdominal fascia and opened at its tip (

A

).

This is easily accomplished by access from theside at the abdominal incision. The abdominalfascia and the peritoneum are incised

crosswise and both, the skin of the umbilicusand the efferent segment of the pouch (ileumnipple or appendix) are spatulated at opposite

sides (

A: dotted lines and B).

a

b


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Figure 20

The efferent segment (ileum nipple orappendix) is pulled through the abdominalwall incision with Allis clamps and secured to

the abdominal fascia with several 2/0polyglycolic acid braided absorbable sutures(A). The skin of the umbilicus and the efferent

segment are anastomosed with 3/0polydioxanone uncoloured monofilamentabsorbable sutures on a cutting needle (B).

The right (posterior) side of the anastomosis iscompleted first, followed by the left (anterior)side, which is readily accessible from the

abdominal incision.

a

b


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Figure 21

A, The medial aspect of the umbilical stoma isbeing completed. An 18 F Foley ballooncatheter is inserted through the umbilical

stoma and the ileal intussusception nippleinto the pouch. Note that in the appendixstoma, the previously before creation of the

submucosal tunnel of the appendix insertedFoley balloon catheter (Fig. 9b) must not beremoved and antegradely reinserted, but

should be retrogradely pulled out through theabdominal incision and the umbilicus beforethe stoma is established as shown in Fig. 20.

Inside the abdomen, the reservoir is suturedagainst the adjacent peritoneum with several3/0 polypropylene sutures (B).

a

b


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Figure 22

At completion of the surgery, the pouch isdrained by a transumbilical Foley catheter andan additional transcutaneous pigtail

pouchostomy catheter. The stents of bothureters are also brought out transcutaneouslyand all catheters are secured to the skin.


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POSTOPERATIVE CARE

Medication. Antibiotics (ampillicin/clavulanicacid and metronidazole) are started beforesurgery and continued for 57 days

afterwards. For postoperative drainage of thestomach, we prefer intraoperative insertion ofa 12 F balloon gastrostomy catheter rather

than a nasogastric tube for patients comfort.Patients are mobilized as early as the first dayafter surgery.

Drains are placed behind the pouch and intothe small pelvis if cystectomy was performed.

The gravity drains are removed as soon as thedrainage is

mainz ii surgery illustrated

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