Robotic revision of ileoanal pouch–in situ pouch inlet reimplantation for chronic stricture: A video vignette

This video presents a complex robotic revision of an ileoanal pouch in a patient with a long-standing W-pouch who developed symptomatic strictures at the pouch inlet. The aim is to highlight the surgical decision-making and technical steps required to preserve pouch function. Preoperative imaging showed a 2.5 cm fibrotic stricture at the pouch inlet with upstream dilatation, and a second 1 cm stricture 7 cm proximally. Despite prior treatment with multiple biologics for a likely diagnosis of Crohn's disease, there was no clinical, endoscopic or radiologic improvement. The patient was motivated to retain the pouch and avoid a permanent stoma. The patient consented to using the video and details of the case for teaching/publication. A 12 mm robotic trocar was inserted at the planned stoma site with three additional 8 mm ports. Extensive adhesiolysis was performed to mobilize the pouch and small bowel. A 20 cm segment of terminal ileum with macroscopic Crohn's-like features was resected. Intraoperative pouchoscopy guided identification and marking of the pouch inlet stricture. A stapled circular anastomosis was attempted but abandoned due to dense perianal scarring and inability to pass the stapler. A full-thickness transabdominal pouchotomy was performed, and a hand-sewn, side-to-end anastomosis between the neo-terminal ileum and the in situ pouch was completed with pouchoscopic assistance. Indocyanine green confirmed adequate perfusion. On-table pouchoscopy and air-leak test confirmed a patent, intact anastomosis. A loop ileostomy was created at the pre-marked site. This case highlights the technical challenges of pouch revision in suspected Crohn's disease with delayed stricture formation. Robotic surgery allows precise dissection and reconstruction in reoperative fields. Hand-sewn anastomosis remains essential when stapling is not feasible. Final pathology showed no definitive Crohn's features, underscoring the complexity of managing late-onset pouch dysfunction (Video 1). Stravodimos Georgios: Writing – original draft; visualization; methodology; writing – review and editing. Giannos Georgios: Writing – original draft; visualization. Lee Yu Jin: Writing – review and editing; supervision. Celentano Valerio: Writing – review and editing; supervision. This paper received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. The authors declare no conflicts of interest. Written informed consent was obtained from the patient for the use of anonymized operative video material for publication. The data that support the findings of this study are available from the corresponding author upon reasonable request.