Background
Laparoscopic total proctocolectomy with ileal pouch anal anastomosis (LPC-IPAA) is considered the most complex procedure amongst all laparoscopic colorectal operations. Controversy exists as to whether clockwise or counterclockwise direction should be adopted for ease of handling and of view during this procedure.

Materials and Methods
Patient charts and operation videos recorded during eight LPC-IPAAs were reviewed. Every important surgical step key to surgical procedure were determined and labeled as part of either clockwise or counterclockwise dissection technique. For comparative analysis, an illustration- enhanced video prototype was rendered.

Result
In the clockwise technique, operation begins with dissection of embryologic plane between the caecum and retroperitoneal structures. The dissection is directed towards the hepatic flexure and proceeds along the transverse mesocolon and gastrocolic ligament concomitantly. This technique has two drawbacks: Ligation and division of IMA and IMV may be compromised by floppy splenic flexure and descending colon. The surgical team might also be tired which in turn can result in a lower quality of mesorectal dissection. In the counterclockwise technique, triangulation and viewing problems may be encountered during dissection of the right and middle colic arteries. We modified and combined two approaches to overcome such problems: We start with the division of IMA and IMV first, continue to mesorectal dissection and switch to clockwise technique at this point. We have been able to save considerable time using this method.

Conclusion
The clockwise and counterclockwise techniques each have their own disadvantages during LPC- IPAA procedure. We believe our modified approach markedly facilitates the procedure.