Kock Pouch Ah
INTERKAL ILEAL
RESERVOIR FOR CONTINENT URINARY DIVERSION
Judy Rauscher, RN: Robert D. Farber, MD; Raul 0. Parra, MD continent internal ileal reservoir (ie. Kock pouch) is one of many techniques .used for continent urinary diversion. It provides a low pressure internal reservoir. true continence. easy catheterization. and reflux prevention. The Kock pouch is an alternative for patients who require a cystectomy or those who have previously undergone urinary diversion via an ileal conduit. wear an external device. and want to improve their quality of life. Creating a Kock pouch is a complex, timeconsuming procedure. A section of ileum is used to make a "neo-bladder" or reservoir with two limbs. The ureters are anastomosed to the afferent limb. and the efferent limb is brought out through the abdominal wall. The neo-bladder collects and stores urine under low pres-
Judy Rauscher, RN. CLIKN. is u irrology clinical niii'se specicilist lit S t Loiris Uiiii~ersity Medic,trl Ceiitei.. S h e eurxed her diploma iri iiiirsiiig ut Jen~ishHospitcil School of' Nirrsiiig. St Loitis. Robert D . Farber, M D . is CI rrrologist at Riimside (Calif) Mcrlic~alClinic. He eurned liis niedicrrl degree (11 St Loiris Uni\wsity School of Mecliciiie.
sure. The patient can catheterize the neo-bladder to empty it at regular intervals.
Patient Selection
A
s with any form of continent diversion, patient selection is very important. Patients should be motivated and have a thorough understanding of the procedure. They must be willing and compliant in participating in their postoperative care. Not all diversion patients are candidates for this procedure. Patients who have had prior abdominal operations followed by high levels of radiation therapy are not good candidates, because effects of high levels of radiation increase the risks in this complex surgery. In addition. obese patients with thick ileal mesentery are at an increased risk for complications. Individuals with impaired renal function (ie, creatinine levels above 2.5 mg/dL) are not good candidates for this procedure. Disruption of the ileal segment to create the Kock pouch can affect bowel absorption. Large shifts of water and solutes occur across the normal intestinal mucosa. which may predispose the patient to metabolic disturbances if he or she has abnormal renal function. This does not affect patients with normal renal function.
T
he patient is admitted to the hospital one day before surgery and receives clear liquids only. Routine preoperative test-
666
AORN JOURNAL
ing includes a chest x-ray, an electrocardiog r a m , a c o m p l e t e blood c o u n t , blood chemistries, coagulation studies. and a routine blood type and cross-match for 2 to 4 units of blood. The patient receives clear liquids and lactated Ringer‘s solution at a rate of 125 to 150 mL/hr intravenously. A mechanical bowel preparation is done. and the patient is started on a wide spectrum of IV and oral antibiotics. The enterostonial therapist sees the patient before and after the surgery. The therapist educates the patient and helps decide on placement of the stoma. The better the patient is informed and prepared, the better the postoperative transition and catheterization experience will go. The nurse evaluates the patient’s ability to move in relation to the positions needed for surgery. He or she also evaluates the patient’s nutritional status and skin condition. As this is a long procedure. skin condition must be monitored carefully. Chronic conditions. such as diabetes, heart disease, and arthritis. also may affect the procedure. The perioperative team must be aware of any such conditions and take appropriate precautions. If the patient has any communication problems (eg. hearing loss), the perioperative nurse should alert the surgical team and the postanesthesia care unit (PACU) nurses. The perioperative team also must be aware of the predetermined stoma placement plan. The nurse should evaluate the patient’s anxiety level. Different patients will have different reactions to this procedure because it may affect their body image. The perioperative nurse can answer questions and offer comfort and support. On the day of surgery. transfer personnel move the patient to the operating room holding area. A nurse meets the patient here and interviews him or her concerning the procedure. allergies. NPO status. and consent form and checks his o r her identification band. The nurse also reviews and evaluates the patient’s preoperative tests. The circulating nurse meets the patient in the operatin2 room and again interviews the
OCTOBER 1992, VOL 56, NO 4
patient concerning allergies, consent form, NPO status, and identification band. The nurse assists the patient onto the warm surgical bed and applies warm blankets. He or she positions a safety strap over the patient. The circulating nurse remains at bedside to provide comfort to the patient and to assist the anesthesiologist as needed. Anesthesia personnel monitor the patient using standard electrocardiogram and pulse oximeter monitors and arterial lines.
1nti.aopesative Care
I
f the patient will be undergoing a cystectomy, the nurse positions him o r her in a modified or low lithotomy position after induction. If the patient is having an ileal conduit converted to a Kock pouch, he or she is placed in the supine position. The perioperative nurse applies pneumatic compression stockings on the patient’s legs to prevent deep venous thrombosis. Intravenous access is maintained, and if indicated, anesthesia personnel insert a pulmonary artery catheter. If the patient has an intact bladder, the nurse inserts an indwelling urinary catheter and connects it to a gravity drainage collection bag. Urine output is monitored every 30 minutes during the procedure. The nurse pads potential pressure areas with foam pads and applies an electrosurgical dispersive pad. He or she preps the patient’s skin from the nipple line to mid-thigh and bedside to bedside, including the perineum, with a povidone-iodine soap and paint solution. While the patient is induced, positioned, and prepped. the scrub nurse prepares the sterile back table and Mayo setup. He or she uses a g e n e r a l l a p a r o t o m y set with e x t r a Kelly clamps and fine needle holders. This set also should have self-retaining retractors, TA-55 and G I A surgical staplers, two #8 feeding tubes, and a #30 Medena tube. A Medena tube is similar to a nonretention catheter with two large offset islets: It is placed in the efferent limb during surgery and acts as a drainage tube and irrigation port for the pouch.
OCTOBER 1992. VOL 56, NO 4
4 0 R h JOCR5AL
Fig 1. The pouch is created from a 78-cm segment of ileum.
T
he surgeon opens the abdominal cavity with a low m i d l i n e incision. I f the patient requires a cystectomy. the surgeon performs that portion of the surgery first and then fashions the Kock pouch. If the patient is undergoing conversion of an ileal conduit to a Kock pouch. the surgeon first lyses adhesions and isolates the ileal conduit. If no radiologic evidence of uretero-ileal obstruction exists. the surgeon will incorporate the base of the ileal conduit into the construction of the pouch. Otherwise, he or she will divide the ureters from the ileal conduit and reimplant
them into the Kock pouch. To form the pouch, the surgeon isolates a 78cm segment of ileum 15 cm proximal to the ileocecal valve (Fig 1). The 17-cm sections on the proximal and distal ends of the segment are used for the efferent and afferent limbs of the pouch. T w o 22-cm sections in the segment’s middle are used for the storage reservoir. It is important to mark each segment with silk sutures to maintain the orientation of the reservoir. The surgeon divides the distal bowel mesentery along an avascular plane, which is located between the ileocolic artery and the superior mesentery a r t e r y . T h e a v a s c u l a r plane i s
OCTOBER 1992, VOL 56. NO 4
AORN JOURKAL
Fig -3. Side-to-side anastomosis of bowel
extended to the base of the mesentery to ensure that the efferent limb is sufficiently mobile. For the proximal limb. the surgeon divides the mesentery for a short distance of approximatel), 5 cm. The surgeon then divides both the proximal and distal bowel with the GIA stapler and reconstructs the bowel with a side-to-side stapled anastomosis (Fig 2 ) . If the patient has an existing conduit. the afferent limb need only be 13 cm Ions, and it will be left open for eventual anastomosis to the base of the ileal conduit. Otherwise, the surgeon now isolates the staples of the afferent limb from the eventual pouch with a running transverse mattress stitch using #3-0 polyglycolic acid ( P G A ) suture (Fig 3 ) . This prevents stone formation that could occur when the staples come i n contact with urine. The two limb\ of the reservoir are n o a formed into a “U”. The
lowest point of the “U” already has been marked with a suture at the point between the two 22-cm segments (Fig 4). The surgeon directs the base of the “U” caudally so the afferent limb can easily be secured to the sacral promontory. Both of the 22-cm segments are joined by running a #3-0 PGA suture opposing the serosa of each segment 2 to 3 segments lateral to its mesentery. The surgeon opens the segments with electrocautery just lateral to the respective serosal suture line resulting in complete detubularization (Fig 5). This incision is carried 3 cm into the efferent limb and 2 cm into the afferent limb beyond the continual serosal suture. This allows the nipple valve to be staggered. The nipple intussusception and fixation does not
Fig 3. A running transverse mattress stitch is used to isolate the staples from the eventual pouch.
OCTOBER 1992, VOL 56, NO 4
involve a continuous serosal suture line along the back of the pouch. After makirig this incision, the surgeon oversews the incised mucosa with a #3-0 PGA continuous suture. The surgeon then constructs the nipple valve. First, he or she opens small windows (ie, Windows of Deaver) in the mesentery for approximately 8 cm along the border of the efferent and afferent limbs of the ileum (Fig 6). Removing the mesentery allows easy intussusception of the ileum into the pouch and avoids any vascular occlusion. The surgeon then passes a 2.5-cm strip of PGA mesh just beyond the window of stripped mesentery, leaving one vascular arcade intact between the mesh on each limb (Fig 7). The mesh will anchor and stabilize the nipple valve after construction. The surgeon passes two Allis clamps approximately two-thirds of the way from
Fig 5. Complete detubularization.
AORN JOURNAL
Fig 4. Note the suture midpoint between the two 22cm segments,
the open ileum to the area of the mesh collar. He or she grasps the mucosa and intussuscepts the ileum into the open pouch forming a nipple (Fig 8). The surgeon uses a TA-55 stapler to insert 4.8-mm staples in four rows parallel to the intussuscepted nipple. These are not hemostatic and do not cross the bowel. Before stapling, the surgeon removes five staples located adjacent to the straight arm of the stapler. It is not desirable for these staples to be placed into the end of the nipple because the staples at the base do not prevent extussusception; in addition, stone formation occurs at the end of the nipple when staples are exposed in this position. Staples near the base of the intussuscepted nipple become buried in the mucosa with time. The surgeon places the fourth row of staples posteriorly to secure the nipple to the back wall of the pouch. The surgeon then sews the mesh circumferentially in place around the efferent and afferent limbs
& 673
OCTOBER 1992. VOL 56, NO 1
AORN JOURNAL
the abdominal wall is slightly smaller than that for an ileal conduit. The surgeon uses a Marlex collar to secure this limb to the rectus fascia with two #1 nylon stitches medial and lateral to the nipple. This prevents a parastomal hernia. The surgeon excises redundant ileum and uses #3-0 PGA sutures to form the stoma and attach it flush with the abdominal wall. A #30 French Medena tube is brought out through the stoma along with the two ureteral stents.
Postoperati\ie Care
Fig 6. Windows of Deaver.
T
he scrub nurse ensures that the dressing is secure and helps remove the surgical drapes. He or she connects the Medena tube to a drainage bag, and each ureteral stent is connected to separate drainage bags and marked "left" and "right" to monitor function of both kidneys. After extubation, the circulating nurse inspects the patient's skin integrity beneath the electrosurgical dispersive pad,
with #2-0 chromic interrupted sutures. Patients with previous ileal conduits already have the base of the conduit secured to the afferent limb; otherwise, each ureteral anastomosis is made into the afferent limb in the standard fashion. The ureters are anastomosed to the afferent limb directly, mucosa to mucosa, to prevent reflux. It is an end-to-side anastomosis, and the surgeon uses #5-0 PGA suture with a #8 French feeding tube to stent the anastomosis. These stents are placed up into the kidney and down into the p o u c h . T h e y e x i t the pouch through the efferent limb. To close the pouch. the surgeon uses a running #3-0 PGA suture in one closely placed layer to ensure watertight closure (Fig 9). After closing the pouch, the surgeon secures the afferent limb of the pouch to the sacral promontory and brings the efferent l i m b out through the abdomen at the predetermined rig 7. A 2.5-cm strip of PGA mesh will anchor the valve. stoma location. The exit hole in 616
OCTOBER 1992, VOL 56. NO 4
AORN JOURNAL
Fig 8. Intussusception of the ileum to form n Ae.
removes the safety strap, and helps the surgical team transfer the patient to the PACU. The pneumatic compression stockings remain on the patient for 48 hours. The Medena tube acts as a drainage tube for the pouch. The pouch must be kept empty during the immediate postoperative period to avoid overdistention and possible rupture. The patient returns to the nursing unit where the nurses irrigate the Medena tube with 60 mL of normal saline every four hours postoperatively. This prevents obstruction of the tube with excess mucus. Before discharge, nurses instruct the patient on the irrigation procedure, because the patient will continue the irrigation schedule for two weeks after discharge. Ureteral stents are left in place for 5 to 7 days or until the patient is eating a reg-
ular diet. The Medena tube is removed two weeks postoperatively. A pouchogram and IV pyelogram are then obtained (Fig 10). Urine is stored in the pouch under low pressure to prevent complications of upper urinary tract deterioration and incontinence. The low pressure in the pouch is important to maintain continence. The patient must learn pouch cathe1.erization and comply with a catheterization schedule (eg, every 2 to 3 hours). The patient is encouraged t o keep a detailed record of each catheterization and amounts of urine collected. The pouch is stretched slowly by increasing the time intervals between catheterizations by one hour every week until intervals of six hours during the day and eight
Fig 9. Completed pouch. 677
Fig 10. Postoperative pouchogram.
hours at night are reached. The Kock pouch has a capacity of 400 to 800 mL after it is established. The pouch is fairly easy to catheterize. because the Marlex collar and the efferent limb are fixed to the anterior rectus fascia. This fixes the continent valve mechanism to the abdominal wall and prevent4 catheterization difficulty by reducing the redundancy of the efferent limb.
repair the valve. Patient difficulty w i t h catheterization may traumatize and contribute to this complication. Postoperative edema may be associated with the mesh. but it does not compromise circulation to the stoma. Postoperatively. nurses routinely monitor stoma circulation and appearance.
Coiicliisiori
P
ossible complications of the Kock pouch procedure are the same as with an ileal conduit. including bowel leaks. obstruction. ileus. and urine leak. Because of the complex nature of this procedure. another complication could be dessusception of the nipple valve. which would require another surgery to
C
reating a Kock pouch is complex and t i m e c o n s u m i n g . It c a n , h o w e v e r , improve the quality of life for certain patients. When choosing the proper technique for an individual patient, care and consideration must be given to the surgeon’s experience and skill. as well as the patient’s motivation and previous medical and surgical treatment.
INTERKAL ILEAL
RESERVOIR FOR CONTINENT URINARY DIVERSION
Judy Rauscher, RN: Robert D. Farber, MD; Raul 0. Parra, MD continent internal ileal reservoir (ie. Kock pouch) is one of many techniques .used for continent urinary diversion. It provides a low pressure internal reservoir. true continence. easy catheterization. and reflux prevention. The Kock pouch is an alternative for patients who require a cystectomy or those who have previously undergone urinary diversion via an ileal conduit. wear an external device. and want to improve their quality of life. Creating a Kock pouch is a complex, timeconsuming procedure. A section of ileum is used to make a "neo-bladder" or reservoir with two limbs. The ureters are anastomosed to the afferent limb. and the efferent limb is brought out through the abdominal wall. The neo-bladder collects and stores urine under low pres-
Judy Rauscher, RN. CLIKN. is u irrology clinical niii'se specicilist lit S t Loiris Uiiii~ersity Medic,trl Ceiitei.. S h e eurxed her diploma iri iiiirsiiig ut Jen~ishHospitcil School of' Nirrsiiig. St Loitis. Robert D . Farber, M D . is CI rrrologist at Riimside (Calif) Mcrlic~alClinic. He eurned liis niedicrrl degree (11 St Loiris Uni\wsity School of Mecliciiie.
sure. The patient can catheterize the neo-bladder to empty it at regular intervals.
Patient Selection
A
s with any form of continent diversion, patient selection is very important. Patients should be motivated and have a thorough understanding of the procedure. They must be willing and compliant in participating in their postoperative care. Not all diversion patients are candidates for this procedure. Patients who have had prior abdominal operations followed by high levels of radiation therapy are not good candidates, because effects of high levels of radiation increase the risks in this complex surgery. In addition. obese patients with thick ileal mesentery are at an increased risk for complications. Individuals with impaired renal function (ie, creatinine levels above 2.5 mg/dL) are not good candidates for this procedure. Disruption of the ileal segment to create the Kock pouch can affect bowel absorption. Large shifts of water and solutes occur across the normal intestinal mucosa. which may predispose the patient to metabolic disturbances if he or she has abnormal renal function. This does not affect patients with normal renal function.
T
he patient is admitted to the hospital one day before surgery and receives clear liquids only. Routine preoperative test-
666
AORN JOURNAL
ing includes a chest x-ray, an electrocardiog r a m , a c o m p l e t e blood c o u n t , blood chemistries, coagulation studies. and a routine blood type and cross-match for 2 to 4 units of blood. The patient receives clear liquids and lactated Ringer‘s solution at a rate of 125 to 150 mL/hr intravenously. A mechanical bowel preparation is done. and the patient is started on a wide spectrum of IV and oral antibiotics. The enterostonial therapist sees the patient before and after the surgery. The therapist educates the patient and helps decide on placement of the stoma. The better the patient is informed and prepared, the better the postoperative transition and catheterization experience will go. The nurse evaluates the patient’s ability to move in relation to the positions needed for surgery. He or she also evaluates the patient’s nutritional status and skin condition. As this is a long procedure. skin condition must be monitored carefully. Chronic conditions. such as diabetes, heart disease, and arthritis. also may affect the procedure. The perioperative team must be aware of any such conditions and take appropriate precautions. If the patient has any communication problems (eg. hearing loss), the perioperative nurse should alert the surgical team and the postanesthesia care unit (PACU) nurses. The perioperative team also must be aware of the predetermined stoma placement plan. The nurse should evaluate the patient’s anxiety level. Different patients will have different reactions to this procedure because it may affect their body image. The perioperative nurse can answer questions and offer comfort and support. On the day of surgery. transfer personnel move the patient to the operating room holding area. A nurse meets the patient here and interviews him or her concerning the procedure. allergies. NPO status. and consent form and checks his o r her identification band. The nurse also reviews and evaluates the patient’s preoperative tests. The circulating nurse meets the patient in the operatin2 room and again interviews the
OCTOBER 1992, VOL 56, NO 4
patient concerning allergies, consent form, NPO status, and identification band. The nurse assists the patient onto the warm surgical bed and applies warm blankets. He or she positions a safety strap over the patient. The circulating nurse remains at bedside to provide comfort to the patient and to assist the anesthesiologist as needed. Anesthesia personnel monitor the patient using standard electrocardiogram and pulse oximeter monitors and arterial lines.
1nti.aopesative Care
I
f the patient will be undergoing a cystectomy, the nurse positions him o r her in a modified or low lithotomy position after induction. If the patient is having an ileal conduit converted to a Kock pouch, he or she is placed in the supine position. The perioperative nurse applies pneumatic compression stockings on the patient’s legs to prevent deep venous thrombosis. Intravenous access is maintained, and if indicated, anesthesia personnel insert a pulmonary artery catheter. If the patient has an intact bladder, the nurse inserts an indwelling urinary catheter and connects it to a gravity drainage collection bag. Urine output is monitored every 30 minutes during the procedure. The nurse pads potential pressure areas with foam pads and applies an electrosurgical dispersive pad. He or she preps the patient’s skin from the nipple line to mid-thigh and bedside to bedside, including the perineum, with a povidone-iodine soap and paint solution. While the patient is induced, positioned, and prepped. the scrub nurse prepares the sterile back table and Mayo setup. He or she uses a g e n e r a l l a p a r o t o m y set with e x t r a Kelly clamps and fine needle holders. This set also should have self-retaining retractors, TA-55 and G I A surgical staplers, two #8 feeding tubes, and a #30 Medena tube. A Medena tube is similar to a nonretention catheter with two large offset islets: It is placed in the efferent limb during surgery and acts as a drainage tube and irrigation port for the pouch.
OCTOBER 1992. VOL 56, NO 4
4 0 R h JOCR5AL
Fig 1. The pouch is created from a 78-cm segment of ileum.
T
he surgeon opens the abdominal cavity with a low m i d l i n e incision. I f the patient requires a cystectomy. the surgeon performs that portion of the surgery first and then fashions the Kock pouch. If the patient is undergoing conversion of an ileal conduit to a Kock pouch. the surgeon first lyses adhesions and isolates the ileal conduit. If no radiologic evidence of uretero-ileal obstruction exists. the surgeon will incorporate the base of the ileal conduit into the construction of the pouch. Otherwise, he or she will divide the ureters from the ileal conduit and reimplant
them into the Kock pouch. To form the pouch, the surgeon isolates a 78cm segment of ileum 15 cm proximal to the ileocecal valve (Fig 1). The 17-cm sections on the proximal and distal ends of the segment are used for the efferent and afferent limbs of the pouch. T w o 22-cm sections in the segment’s middle are used for the storage reservoir. It is important to mark each segment with silk sutures to maintain the orientation of the reservoir. The surgeon divides the distal bowel mesentery along an avascular plane, which is located between the ileocolic artery and the superior mesentery a r t e r y . T h e a v a s c u l a r plane i s
OCTOBER 1992, VOL 56. NO 4
AORN JOURKAL
Fig -3. Side-to-side anastomosis of bowel
extended to the base of the mesentery to ensure that the efferent limb is sufficiently mobile. For the proximal limb. the surgeon divides the mesentery for a short distance of approximatel), 5 cm. The surgeon then divides both the proximal and distal bowel with the GIA stapler and reconstructs the bowel with a side-to-side stapled anastomosis (Fig 2 ) . If the patient has an existing conduit. the afferent limb need only be 13 cm Ions, and it will be left open for eventual anastomosis to the base of the ileal conduit. Otherwise, the surgeon now isolates the staples of the afferent limb from the eventual pouch with a running transverse mattress stitch using #3-0 polyglycolic acid ( P G A ) suture (Fig 3 ) . This prevents stone formation that could occur when the staples come i n contact with urine. The two limb\ of the reservoir are n o a formed into a “U”. The
lowest point of the “U” already has been marked with a suture at the point between the two 22-cm segments (Fig 4). The surgeon directs the base of the “U” caudally so the afferent limb can easily be secured to the sacral promontory. Both of the 22-cm segments are joined by running a #3-0 PGA suture opposing the serosa of each segment 2 to 3 segments lateral to its mesentery. The surgeon opens the segments with electrocautery just lateral to the respective serosal suture line resulting in complete detubularization (Fig 5). This incision is carried 3 cm into the efferent limb and 2 cm into the afferent limb beyond the continual serosal suture. This allows the nipple valve to be staggered. The nipple intussusception and fixation does not
Fig 3. A running transverse mattress stitch is used to isolate the staples from the eventual pouch.
OCTOBER 1992, VOL 56, NO 4
involve a continuous serosal suture line along the back of the pouch. After makirig this incision, the surgeon oversews the incised mucosa with a #3-0 PGA continuous suture. The surgeon then constructs the nipple valve. First, he or she opens small windows (ie, Windows of Deaver) in the mesentery for approximately 8 cm along the border of the efferent and afferent limbs of the ileum (Fig 6). Removing the mesentery allows easy intussusception of the ileum into the pouch and avoids any vascular occlusion. The surgeon then passes a 2.5-cm strip of PGA mesh just beyond the window of stripped mesentery, leaving one vascular arcade intact between the mesh on each limb (Fig 7). The mesh will anchor and stabilize the nipple valve after construction. The surgeon passes two Allis clamps approximately two-thirds of the way from
Fig 5. Complete detubularization.
AORN JOURNAL
Fig 4. Note the suture midpoint between the two 22cm segments,
the open ileum to the area of the mesh collar. He or she grasps the mucosa and intussuscepts the ileum into the open pouch forming a nipple (Fig 8). The surgeon uses a TA-55 stapler to insert 4.8-mm staples in four rows parallel to the intussuscepted nipple. These are not hemostatic and do not cross the bowel. Before stapling, the surgeon removes five staples located adjacent to the straight arm of the stapler. It is not desirable for these staples to be placed into the end of the nipple because the staples at the base do not prevent extussusception; in addition, stone formation occurs at the end of the nipple when staples are exposed in this position. Staples near the base of the intussuscepted nipple become buried in the mucosa with time. The surgeon places the fourth row of staples posteriorly to secure the nipple to the back wall of the pouch. The surgeon then sews the mesh circumferentially in place around the efferent and afferent limbs
& 673
OCTOBER 1992. VOL 56, NO 1
AORN JOURNAL
the abdominal wall is slightly smaller than that for an ileal conduit. The surgeon uses a Marlex collar to secure this limb to the rectus fascia with two #1 nylon stitches medial and lateral to the nipple. This prevents a parastomal hernia. The surgeon excises redundant ileum and uses #3-0 PGA sutures to form the stoma and attach it flush with the abdominal wall. A #30 French Medena tube is brought out through the stoma along with the two ureteral stents.
Postoperati\ie Care
Fig 6. Windows of Deaver.
T
he scrub nurse ensures that the dressing is secure and helps remove the surgical drapes. He or she connects the Medena tube to a drainage bag, and each ureteral stent is connected to separate drainage bags and marked "left" and "right" to monitor function of both kidneys. After extubation, the circulating nurse inspects the patient's skin integrity beneath the electrosurgical dispersive pad,
with #2-0 chromic interrupted sutures. Patients with previous ileal conduits already have the base of the conduit secured to the afferent limb; otherwise, each ureteral anastomosis is made into the afferent limb in the standard fashion. The ureters are anastomosed to the afferent limb directly, mucosa to mucosa, to prevent reflux. It is an end-to-side anastomosis, and the surgeon uses #5-0 PGA suture with a #8 French feeding tube to stent the anastomosis. These stents are placed up into the kidney and down into the p o u c h . T h e y e x i t the pouch through the efferent limb. To close the pouch. the surgeon uses a running #3-0 PGA suture in one closely placed layer to ensure watertight closure (Fig 9). After closing the pouch, the surgeon secures the afferent limb of the pouch to the sacral promontory and brings the efferent l i m b out through the abdomen at the predetermined rig 7. A 2.5-cm strip of PGA mesh will anchor the valve. stoma location. The exit hole in 616
OCTOBER 1992, VOL 56. NO 4
AORN JOURNAL
Fig 8. Intussusception of the ileum to form n Ae.
removes the safety strap, and helps the surgical team transfer the patient to the PACU. The pneumatic compression stockings remain on the patient for 48 hours. The Medena tube acts as a drainage tube for the pouch. The pouch must be kept empty during the immediate postoperative period to avoid overdistention and possible rupture. The patient returns to the nursing unit where the nurses irrigate the Medena tube with 60 mL of normal saline every four hours postoperatively. This prevents obstruction of the tube with excess mucus. Before discharge, nurses instruct the patient on the irrigation procedure, because the patient will continue the irrigation schedule for two weeks after discharge. Ureteral stents are left in place for 5 to 7 days or until the patient is eating a reg-
ular diet. The Medena tube is removed two weeks postoperatively. A pouchogram and IV pyelogram are then obtained (Fig 10). Urine is stored in the pouch under low pressure to prevent complications of upper urinary tract deterioration and incontinence. The low pressure in the pouch is important to maintain continence. The patient must learn pouch cathe1.erization and comply with a catheterization schedule (eg, every 2 to 3 hours). The patient is encouraged t o keep a detailed record of each catheterization and amounts of urine collected. The pouch is stretched slowly by increasing the time intervals between catheterizations by one hour every week until intervals of six hours during the day and eight
Fig 9. Completed pouch. 677
Fig 10. Postoperative pouchogram.
hours at night are reached. The Kock pouch has a capacity of 400 to 800 mL after it is established. The pouch is fairly easy to catheterize. because the Marlex collar and the efferent limb are fixed to the anterior rectus fascia. This fixes the continent valve mechanism to the abdominal wall and prevent4 catheterization difficulty by reducing the redundancy of the efferent limb.
repair the valve. Patient difficulty w i t h catheterization may traumatize and contribute to this complication. Postoperative edema may be associated with the mesh. but it does not compromise circulation to the stoma. Postoperatively. nurses routinely monitor stoma circulation and appearance.
Coiicliisiori
P
ossible complications of the Kock pouch procedure are the same as with an ileal conduit. including bowel leaks. obstruction. ileus. and urine leak. Because of the complex nature of this procedure. another complication could be dessusception of the nipple valve. which would require another surgery to
C
reating a Kock pouch is complex and t i m e c o n s u m i n g . It c a n , h o w e v e r , improve the quality of life for certain patients. When choosing the proper technique for an individual patient, care and consideration must be given to the surgeon’s experience and skill. as well as the patient’s motivation and previous medical and surgical treatment.
