Restorative total proctocolectomy with ileoanal pouch anastomosis may not be feasible in some patients due to technical intraoperative limitations.Assess preoperative predictors for intraoperative ileoanal pouch abandonment and review management.Retrospective review.Cleveland Clinic Florida between January 2010 to May 2018.Patients >18 years who underwent ileoanal pouch surgery. Patients with successful pouch creation as planned were grouped as 'successful ileoanal pouch anastomosis creation'. Operative reports of patients who underwent alternative procedures were reviewed to identify cases when the pouch was preoperatively planned but intraoperatively abandoned (ileoanal pouch anal anastomosis abandoned group). Multivariate logistic regression models were developed to determine predictors of intraoperative pouch abandonment. We also reviewed management of patients who failed initial pouch creation.Preoperative predictors for intraoperative ileoanal pouch abandonment.A total of 1438 patients were offered an ileoanal pouch; 21 (1.5%) experienced pouch abandonment due to inadequate reach (n=17) and other technical reasons (n=4). These patients underwent alternative procedures such as end or loop ileostomy with/without proctectomy. Multivariate logistic regression analysis indicated male gender (OR 6.021, 95% CI: 1.540-23.534), body mass index (OR 1.217, 95% CI: 1.114-1.329) and 2-staged procedure (OR 14.510, 95% CI: 4.123-51.064) as independent factors associated with intraoperative abandonment of pouch creation. Alternative procedures were total proctocolectomy with end ileostomy (n=14) and total abdominal colectomy with end ileostomy without proctectomy (n=7). Ultimately, pouch creation was achieved in 6/21 patients after median interval of 8.8 (range, 4.1-34.8) months. All patients had intentional weight loss prior to reattempt and total abdominal colectomy with end ileostomy without proctectomy as their initial procedure.Retrospective nature.Ileoanal pouch abandonment is rare and can be mitigated by initial total abdominal colectomy and weight loss. Male, obese patients are at higher risk of failure. Intraoperative assessment of ileoanal pouch feasibility should occur prior to rectal dissection. See Video Abstract at http://links.lww.com/DCR/B156.