A 28-year-old female with a history of Crohn’s disease for 9 years. The patient had tried several treatments, which had only been effective temporarily. Finally, the patient had been taking adalimumab with poor control. The patient had presented with recurring episodes of obstruction over the last few months. On imaging, a 10 cm stenosis on the distal ileum was causing dilation of the proximal bowel. Prior endoscopic dilations of this segment had been attempted with no clinical improvement. Thus, the patient was proposed to undergo a laparoscopic ileocecal resection.
Three trocars were used: a 12 mm umbilical port for the optic and two 5 mm trocars on the left lower quadrant and left upper quadrant. The cavity was explored to identify the diseased segment macroscopically on the distal ileum, which was adjacent to the ileocecal valve.
The right colon was mobilized laterally starting at the cecum. The ileocecal vessels were identified. The vascular dissection began by opening a window on the peritoneum. Once skeletonized, an energy device was used to transect the vessels. The retroperitoneal plane was mobilized medial to lateral, reaching the level of the transection on the ascending colon which had previously been defined as healthy tissue. Once the place of section was identified, an EndoGIA was used to transect the colon.
Then, the distal ileum was examined once again to delimitate the proximal section point, in order to resect all the diseased bowel segment. Approximately 50 cm of ileum appeared to be affected macroscopically. The meso was dissected reaching the chosen point of transection at the ileum, which was cut with an EndoGIA. The specimen was extracted through a Pfannenstiel incision, where an Alexis had been previously placed.
In order to prepare for the intracorporeal anastomosis, the ileum was brought closer to the colon. With the aid of a fabric ribbon, the point of the anastomosis is marked. First, the colon is opened followed by the opening in the distal ileum at the same level.
The intracorporeal ileocolic anastomosis was performed with an EndoGIA adjusting each blade to the colon and the small bowel. Once fired, the stapler is removed and the mechanic anastomosis is widely open with no signs of active bleeding.
To close the gap, a stitch was placed superiorly that would later continue with the running suture closing the orifice through which the staple had been placed. The stitch is tied and the needle is kept in place. Afterwards, an interrupted single stitch is placed on the inferior side of the gap, tied and cut with long ends. The first stitch made will be the start for a running suture. The end of this running suture will be tied to the interrupted stitch made at the other side of the gap. Additional stitches can be placed between the ileum and the colon in order to release some tension from the anastomosis.
Operative time was 95 minutes. The patient had an uneventful postoperative period, and left hospital on the third postoperative day. No complications have been found on the 4 weeks of follow-up.
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