Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is the mainstay of surgical treatment for patients with inflammatory bowel disease and familial adenomatous polyposis. Since its introduction, advances in surgical techniques, perioperative care, and multidisciplinary management have improved outcomes and expanded the applicability of ileal pouch surgery. Despite these advances, successful pouch construction and long-term function remain dependent on surgical skill, intraoperative decision-making, and appropriate management of complications.

This narrative review describes the evolution, outcomes, and technical considerations of RP/IPAA, with emphasis on operative strategies and contemporary approaches to postoperative complications including pouch salvage.

RP/IPAA provides durable preservation of intestinal continuity. Though bowel function varies, patient-reported quality of life postoperatively is generally high. Technical factors of surgery, including pelvic dissection, pouch construction, and pouch-anal anastomosis can substantially influence functional and surgical outcomes. Management of pouch-related complications requires careful identification of the underlying etiology, and consideration of both surgical and nonsurgical treatment options. In select patients, pouch salvage, augmentation, and redo pouch surgeries can restore pouch function. Given the technical complexity of primary and revisional pouch surgery, outcomes are optimized when patients are managed by experienced surgical teams at high-volume centers.

RP/IPAA has transformed the surgical management of patients requiring proctocolectomy by providing an option for intestinal continuity in lieu of permanent ostomy. Optimal outcomes require deliberate patient selection, honed surgical technique, and comprehensive postoperative management. When pouch-related complications occur, evaluation at specialized referral centers may maximize the potential for pouch preservation.