**6.1 RPC-IPAA procedure**

RPC with IPAA is a procedure that can be made in one, two, or three stage, by laparoscopic or open surgery.

The laparoscopic approach, if feasible, allows better cosmetics and outcomes. One-stage or two-stage procedure is recommended for elective surgery and three-stage for emergent surgery.

Stage 1—An ileal pouch is made, and anastomosed to the anus is made after de proctocolectomy without a protective ileostomy. The operation is made in elective surgery and completed in a single stage (one surgery).

Stage 2—After a PC and IPAA confection, the anastomosis is protected by a loop ileostomy, and ileostomy closure is posterior realized (two surgeries).

Stage 3—At the emergency room, the first step is the total abdominal colectomy and ileostomy. The second step is the IPAA with the anastomosis protected by a loop ileostomy. The third surgery is the ileostomy closure (three surgeries).

Due to anastomotic complications (infection, fistulization, development of Crohn's disease, disease recurrence, or poor function), an ileostomy may be required (stage 2) to prevent complications or if the pouch fails postoperatively. The authors are not unanimous about the need to do a derivative ileostomy by routine during IPAA construction (stage 1 vs. stage 2).

Lovegrove et al. found to be associated with ileostomy omission: stapled anastomosis (odds ratio [OR], 6.4), no preoperative corticosteroid use (OR, 3.2), familial adenomatous polyposis diagnosis (OR, 2.6), cancer diagnosis (OR, 3.4), female sex (OR, 1.6), and age at surgery younger than 26 years (OR, 2.1) (*p* < 0.01 for all). They are convinced that incorporating a five-point nomogram in the preoperative assessment of patients undergoing RPC might help clinicians identify a select group of patients who may be candidates for ileostomy omission during RPC [27]. Karjalainen et al. showed in their study that a diverting ileostomy is associated with considerable morbidity, and it does not seem to prevent later failure of the pouch. Therefore, they suggest that a diverting ileostomy should only be constructed for high-risk patients [28]. On the other hand, Rottoli et al. demonstrated that closure of ileostomy after three-stage IPAA is associated with a low rate of serious complications, despite the higher number of previous abdominal surgeries, supporting the construction of routine ileostomy during IPAA to reduce the risk of pelvic sepsis [29].
