The diagnosis and primary treatment of UC is conservative and lies in the hands of gastroenterologists. Surgery is an option for patients who are refractory to treatment and/or who present with dys- or neoplastic lesions. In children and adolescents, growth retardation may be another indication to proceed with surgery. Both indeterminate colitis and Crohn’s colitis without anorectal manifestation are no longer considered an absolute contraindication; however, it is mandatory to inform patients about the increased rate of pouch failure in these cases (approx. twofold compared with UC).

To determine the timing for prophylactic surgery in FAP patients, both the phenotype (clinical manifestation) and symptoms should be taken into account. Molecular genetic proof of the diagnosis of FAP and detection of a pathogenic mutation in the APC gene are preferable but not indispensable prior to surgery. The lack of proof of the underlying genetic cause does not influence the surgical indication. Symptoms that should drive toward prompt surgery include growth retardation, diarrhea, chronic anemia, or abdominal pain. A recently implemented international staging system, which classifies size, distribution, and histology of adenomas in FAP in conjunction with a recommended therapeutic strategy, is helpful and should be applied as preoperative score [4].

In classic FAP without cancer, as a basic principle one-stage laparoscopic (also secondary to previous abdominal surgery) proctocolectomy is pursued, whereas for the attenuated phenotype, laparoscopic (sub)total colectomy is the procedure of choice. The indisputable and clear advantage of the laparoscopic approach, including the beneficial effect on female fertility, is well-documented [5, 6].

As our general strategy, we aim to avoid both larger incisions and a routine protective ileostomy, to leave the omentum, and to perform a TME, if applicable as a transanal laparoscopic TME (taTME). If the laparoscopic approach is not feasible for technical reasons, our preference is a small Pfannenstiel incision and a hand-assisted completion of the colectomy. A deviation stoma is avoided in favor of a virtual ileostomy, as has been described by the authors [10], in conjunction with an anal tube, unless the tension of the pouch mesentery is worrisome or a primary anastomotic leak is demonstrated.

In the event of UC, indeterminate colitis, or Crohn’s disease, for reasons stated earlier, the primary laparoscopic approach for elective surgery is preferred, mostly as a two-stage procedure. In the emergency setting or in comorbid and immunosuppressed patients, an initial subtotal colectomy with preservation of a sufficiently long rectal remnant and terminal ileostomy, if possible laparoscopically with a single-port approach (at the site of the future ileostomy), is recommended. Consecutively, the single-port site is used for colonic specimen extraction and for fashioning of the terminal ileostomy. Laparoscopic completion proctectomy is pursued once the patient has recovered and medication can be reduced or omitted. Again, the single-port incision will be employed by closing the detached terminal ileum, repositioning into the abdomen for the abdominal preparation and rendezvous approach. The ileoanal pouch will later, by detaching the embryonic adhesions at the height of the sigmoid colon and moving proximally after long-segment visualization of the left ureter, be fashioned exteriorly after mobilization of the small bowel. A consecutive deviation will generally be avoided, especially since the mesentery is spontaneously elongated after a deviating ileostomy and therefore the pouch-anal anastomosis is generally tension-free.

Since the introduction of taTME (in 2015) at our institution, we have operated on 12 patients following the approach described herein. We diagnosed one abscess posterior to the pouch in one patient on the ninth postoperative day, which was successfully drained with an interventional tube. One case of reduced vascularization of the short limb of the J‑pouch has already been described elsewhere [14]. In all cases, the virtual ileostomy was removed between days 3 and 9. In the early postoperative course, one patient had a singular nocturnal experience of incontinence after removal of the anal drain. Patients were dismissed between postoperative days 10 and 16 with complete oral intake, complete continence, and medication of a maximum of six tablets of loperamide per 24 h.

1: In order to achieve tension-free length of the mesentery for construction of the pouch, complete mobilization of the terminal ileum and the mesenteric pedicle is mandatory The Heidelberg school of Prof. Herfarth insisted on preservation of both the ileocolic and the mesenteric vascular arcades, with the aim of maintaining a double-fold vascular supply. In principle, however, only one of the two is required and either may be sacrificed for achievement of greater lengthening. In the Anglo-American literature, the general recommendation is to routinely transsect the ileocolic pedicle [7].

2: The crucial argument for avoiding a routine ileostomy in FAP patients is the increased posttraumatic induction of desmoid growth observed at this site [8]. In addition, fashioning and taking down of an ileostomy are associated with substantial morbidity. By performing a virtual ileostomy, additional safety may be achieved in the event a secondary deviation is required, since the prepared loop of small bowel may easily be exteriorized without the requirement of a relaparotomy [9]. The combination with an anal tube contributes to the overall concept, although this lacks documented evidence. A benefit for the approach of an anal tube has been described for rectal surgery [11]. In the event of an ileoanal pouch, the postulated beneficial effect has yet to be prospectively validated.

3: taTME with a “bottom–up” approach in the hands of the experienced offers the advantage of a potentially improved preservation of continence and of urogenital function [12]. Neuromapping may offer additional safety for nerve preservation. The feasibility of an ileoanal pouch construction with taTME and ileal pouch–anal anastomosis (IPAA) for UC was first described in 2015 [13]. Our experience with our first series of FAP patients was recently published [14]. As a rendezvous procedure with excellent visualization of the TME sheath, this procedure must be prospectively documented and evaluated regarding outcome—specifically QoL—for benign indications.

According to Bartels et al. [15], most surgeons perform TME as part of proctocolectomy and only a few opt for close rectal dissection (CRD). Both methods have advantages and disadvantages. In a small prospective randomized study, no difference between the procedures was found after 12 months, neither in terms of functional results nor in QoL. However, the CRD group had a lower incidence of complications. The extent to which taTME contributes to fewer complications and thus shifts the argument in favor of TME must be critically evaluated. In our experience, transanal manipulation did not have any negative effects in the small group of patients. The advantage of the double purse-string suture is that it allows for exact height determination of the anastomosis and a better circulation of the bilateral circular anastomosis with more effective removal of the rectal margin Whether this leads to a lower rate of insufficiency, better function, and avoidance of cuffitis and rectal neoplasia must be evaluated prospectively.