The mesenteric sling technique

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In 1967, Kock1 devised a continent ileostomy consisting of a low pressure terminal ileal reservoir and an outlet. At first, the indications for this procedure included proctocolectomy for ulcerative colitis, familial polyposis, and in some instances Crohn’s disease. It soon became obvious, however, that the risks of constructing a reservoir in a patient with Crohn’s disease were considerable, and now Crohn’s disease is a definite contraindication. Since 1967, there have been several technical modifications mainly associated with the outlet mechanism. These have been necessitated by a considerable reoperation rate for incontinence.

In the original procedure the terminal ileum distal to the reservoir was simply brought out obliquely through the rectus muscle and excised flush with the skin. No special valvular mechanism was constructed and continence depended on the sphincteric action of the rectus muscle on the terminal ileum. Some of these patients did well and remained continent, but in many patients incontinence developed, and the concept of the nipple valve was devised by Kock.

The nipple valve is constructed by intussuscepting 8 cm of the terminal ileum into the reservoir and, indeed, it does function as a continent valve as long as the intussusception is maintained. Unfortunately it has a natural tendency to dessuscept. This usually occurs on the mesenteric side, presumably because this is the bulkier and more difficult side to fix. The first signs usually occur after the third postoperative month. The patient usually complains of difficulty in catheterizing the reservoir and soon incontinence develops.

Several methods have . . .



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