Ileal pouch-anal anastomosis (IPAA) is the procedure of choice for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The procedure requires resection of the entire colon and rectum, creation of an ileal pouch, and anastomosis of the pouch to the anal canal, which is extensive and time-consuming. The key lies in the production and anastomosis of the pouch, which has certain skills and difficulties. This article gives a brief description of how to complete the procedure. The first part of the surgery: total colorectal resection This part can be done laparoscopically. Generally, the sigmoid colon and rectum are separated first, then the right hemicocele is separated, and finally the whole colorectum is free at the transverse colonic division, and the intestinal canal is separated at the lower rectum, and the anastomosis is completed by preserving 1-2 cm of the anal canal. The key points here are to free the lower rectum to the lowest possible position, remove the whole rectum mesentery, and preserve the shortest anal canal to complete the anastomosis. The second part of the procedure: determining whether the anastomosis between the reservoir bag and the anal canal can be completed This step is crucial and must be performed before the creation of the reservoir bag. Neglecting this step is likely to result in the pouch not being able to anastomose with the anal canal once it is made. The most accurate way to determine the shape of the pouch is to virtually pull it to the pelvic floor with one hand and use a double-combination approach with the other hand. Other methods such as using the pubic symphysis as a basis for judgment still run the risk of being inaccurate. The ileocolic artery must be dissected, otherwise it is difficult to anastomose the pouch to the anal canal. The third part of the procedure: creation of the pouch The pouch is created by folding the end of the ileum into a “J” shape and using an anastomosis or sutures. The two segments of the “J” canal are approximately 15-25 cm long. The specific length depends on whether the anastomosis can be completed, but generally should not be shorter than 12 cm, otherwise the postoperative stool is more frequent. Storage bag according to the configuration of “S”, “J”, “W” and so on. Although the capacity of the J bag is smaller, but the use of anastomosis production is simple, and long-term bag function and other configurations are not significantly different, has become the standard procedure. However, if the “J” pouch cannot be anastomosed in any way, the “S” pouch can be made and a manual anastomosis performed. The fourth part of the procedure: completion of the anastomosis is usually performed with a 29-gauge anastomosis. It is important to be gentle when inserting the anastomosis, otherwise breaking the retained anal canal tissue will have disastrous consequences and the anastomosis may never be completed. The tethered side is usually placed posteriorly, i.e., anterior to the sacrum. The anastomotic exit needle should also be placed posteriorly in the rectum, avoiding the anterior tissues (especially in women), to avoid embedding in the surrounding tissues and leading to complications. Part 5 of the procedure: What to do if the anastomosis is difficult A good blood supply, absence of tension, and nutritional status are the guarantees of a safe anastomosis. In some cases, even if it is clear that the anastomosis can be completed before making the storage bag, there are still cases where the actual anastomosis is difficult. In such cases, mesenteric windowing, freeing the superior mesenteric artery up to the duodenal level, further dissection of the vessel (which is risky), vascular grafting, and leaving the pouch unattended until the second surgery can be performed. Conclusion: IPAA allows patients to defecate by the anus, avoiding stoma, thus significantly improving their quality of life, and those with intact storage pouch function are closer to normal. Surgical excision of the site of morbidity eliminates the risk of cancer, and postoperative frequency of stool, the feeling of urgency disappears, and dietary restrictions are less frequent, making it the choice of more and more UC patients. The above points should be noted in the process of pouch surgery, otherwise it will affect the function of the pouch and cause many, many complications.