with Dr. Salvadora Delgado, Dr. Ainitze Ibarzabal
A 30 years old female presented recurrent abdominal pain and distention so underwent a colonoscopy that showed erosion and ulcers at the mucosa of the ileocecal valve, with a deformed cecum that didn't allow the visualization of the ileum. Several biopsies were taken demonstrating changes that suggests Crohn´s disease.
A MRI was also performed showing inflammatory changes at the small bowel with a stenotic segment of ileum, sings of subocclusion and a entero-enteric fistula complicated with a collection.
Anti TNF plus Azathioprine and budesonide was administered with a lack of improvement of the symptoms so an ileocecal resection was proposed.
The approach was accomplished by laparoscopy. A total of three trocars were used, one of 12 mm at the left lateral of the umbilicus for a 30º camera and two of 5 mm, one at the epigastrium and other at suprapubic position. Abdominal cavity examination revealed inflammatory changes of the ascending colon (adhesion to the abdominal wall) and a thickened terminal ileum.
The dissection is made from medial to lateral, by using the hook and opening the peritoneum of the mesocolon that is located just inferior to the right colic vessels, the suction helps with blunt dissection through the posterior plane, notice that patients with IBD tend to bleed more easily.
Mobilization progress by cutting the lateral attachment of the colon and the mesentery of the terminal ileum, once again edema and blood are present. A small pfannenstiel incision is performed and a protective bag is placed, the specimen is exteriorized and prepared for section with mechanical staplers firing.
In this case the colon is reintroduced in the abdominal cavity to allow the extraction of the edematous ileum. The mesentery is sectioned between clamps and reinforced with a running monofilament suture to decrease the risk of bleeding. The transit is rebuilt by a side-to-side mechanical ileo colonic anastomosis and finally a drain is placed.
The incision measured 5 cm and the skin closed with running monofilament sutures. At the macroscopic examination there is an extensive affectation of the colon and terminal ileum.
The pathology confirmed a Crohn´s disease. The patient started the oral intake the second postoperative day and was discharged 4 days after surgery without complications.
The last follow up was three years after this episode and there is no relapse.
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