Chapter 189: Supravesical Urinary Diversion
Ileal Pouches
Three general types of ileal pouches have been
described: the Kock pouch, the ileo-cecal Mainz
pouch, and the various orthoto-pic pouch
configurations (described later), which can be
used in a heterotopic location with the
application of a Monti or Mitrofanoff
catheterizable channel. The Kock pouch is
rarely performed in the modern era due to its
complexity and high rate of complications. It is
not described further in this text.
The ileocecal Mainz pouch combines the
distal ileum and cecum in a pouch with a
separate ileal segment for a catheterizable
A
H
R
B
Fig. 10. Mainz pouch. A: The pouch is created from 10 to 15 cm of detubularized ascending colon and 20
to 25 cm of detubularized terminal ileum folded in an S-shape. Another more proximal 10-cm segment
of ileum is not detubularized. B: The proximal nondetubularized ileum is intussuscepted into the pouch
and through the preserved ileocecal valve. This double intussusception is secured with staples.
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channel while preserving the ileocecal valve
for continence (Fig. 10). One isolates 10 to
15 cm of cecum and the right colon, two 10-
to 15-cm segments of the distal ileum, and a
20- to 25-cm segment of ileum just proximal
to that. The cecal segment and two 10- to 15-
cm ileal segments are detubularized and sewn
side to side in an “S” configuration to form
the posterior plate of the pouch, tak-ing care
to preserve the ileocecal valve. The other
ileal segment serves as the efferent limb. It is
separated from its mesentery for 6 to 8 cm
and intussuscepted into the poste-rior plate of
the pouch. The intussusception
F
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0
6 over a distance of 3 cm and the catheteriz-
is stabilized with two passes of a noncutting
stapler. The stabilized segment is then passed
through the ileocecal valve and sta-bilized
again with the stapler. The pouch is closed
and the effect limb is brought out through the
rectus fascia and skin.
Any ileal pouch can serve as a heterotopic
reservoir, including those originally intended as
orthotopic pouches. However, without an
ileocecal valve to serve as a continent cathe-
terizable segment, one must rely on a tun-neled
appendix or ileum. When using the il-eum as
the catheterizable channel, one minimizes the
amount of bowel that must be resected by using
the Monti technique rather than by simply
tapering a long segment of il-eum (Fig. 11). In
this manner, 2 cm of ileum is harvested and
opened lengthwise 2 cm from the mesenteric
border. The bowel is then closed transversely
such that the mucosal folds are oriented along
the length of the channel. The closure is done
over a 12F or 14F catheter with absorbable
sutures. In adults, in order to achieve enough
narrowing of the channel over the catheter we
often find it necessary to imbricate a second
layer of clo-sure in a Lembert fashion. Because
this layer will be extraluminal, we use
permanent su-tures. Because the bowel is
opened closer to the mesentery on one side, the
mesentery will attach closer to one end of the
catheter-izable channel. This allows the surgeon
some flexibility in putting the shorter end
through the pouch and freeing up the longer end
to traverse to the skin, or vice versa. Submu-
cosal tunneling into the pouch is done as
originally described by Mitrofanoff, which is
similar to that described by Leadbetter and
Clarke for extracolonic ureteral implanta-
tion. The serosa and muscularis are elevated
able segment lain in the trough. A small hole
is created in the end of the bowel mucosa and
a mucosa-to-mucosa anastomosis performed
between the catheterizable segment and the
pouch. The Monti technique yields a channel
that is about 6 cm in length. When longer
Nongastrointestinal Transabdominal Surgery
segments are required one can use a spiral
Monti or double Monti. In the double Monti
two Monti segments are sewn end to end. In
the spiral Monti described by Casale, a 4-cm
ileal segment is detubularized on one side
of the mesentery for half the length of the
bowel, the incision is brought across the bowel
to the opposite mesentery, and the remainder
of the bowel is opened along that mesentery.
When the bowel is closed longitudinally the
reconfiguration is in a spiral (Fig. 12).
Orthotopic Pouches
The original orthotopic diversion was the
Camey procedure, using a nondetubularized
ileal segment. This has been abandoned due