MIS in a complex case of Crohn's disease

Case

A 34-year-old male with a previous history of Crohn’s disease controlled with Infliximab was admitted to the hospital due to abdominal pain and fever. A CT scan and a colonoscopy showed that there were inflammatory changes in the terminal ileum, cecum, and a suspected fistula between the ileum and the sigmoid colon.

Medical treatment was initiated with parenteral nutritional support and corticoids, but it was unsuccessful. The patient had persistent abdominal pain, diarrhoea and fever, so surgical treatment was recommended.

Treatment

The procedure was carried using a laparoscopic approach. The patient was placed in the supine position, with the leading surgeon standing on the left plus two assistant surgeons, one on each side of the patient.

A total of four trocars were used: a 12-mm trocar to the left of the umbilicus for a 30° scope and three trocars of 5 mm located at  the epigastrium, hypogastrium and the right iliac fossa.

Examination of the abdominal cavity revealed a plastron that involved the terminal ileum, the cecum and the sigmoid colon. There were marked inflammatory changes and fibrine. There were adhesions between the small bowel and the sigmoid colon.

Blunt dissection is mandatory to individualise the plastron. keeping in mind the delicate tissues, which tend to bleed. Traction and countertraction manoeuvres are used in the areas attached by firm adhesions.

Step by step, the terminal ileum was detached from the sigmoid colon, and it looked like there was no fistula. Now the goal was to perform an ileocecal resection. The strategy was to mobilize the colon from lateral to medial.

Careful inspection of the right iliac fossa leads to the identification of the appendix that is used for traction and to guide the initial phase of the mobilization. Suction is used to open a small window at the peritoneum. The edema helps to identify an avascular plane that must be followed to avoid bleeding.

The Ligasure makes it possible to detach the colon from the cecum to the hepatic flexure. At this stage the assistant surgeon performs cranial traction of the colon, improving the exposure.

Once the mobilization was finished, incision of assistance was performed, enlarging the wound of the 5mm trocar located at the right iliac fossa. A protective bag was placed and the specimen was carefully extracted.

The small bowel was thickened with a bulky mesentery. To preserve the incision, the ileum was sectioned and re-introduced into the abdominal cavity.

The colon was extracted step by step. Section of the mesentery was performed in a special manner to ensure control over bleeding. The Ligasure™ seals and cut and a clamp were used to hold the proximal aspect, then a prolene running suture was used to securely seal the vessels. The cecum was exteriorized until the unaffected colon was identified. The section was performed using mechanical suture.

The terminal ileum was then examined. No stenosis or perforation were found. The section was performed at a area of healthy tissue and its mesentery was also carefully prepared.

A mechanical latero-lateral ileocolic anastomosis was performed to restore bowel transit. A knot was made to prevent tension. The organs were restored into the abdominal cavity and the abdominal wound was closed.

Laparoscopic lavage using an iodine solution was carried out, and a drain was placed for surveillance.

Outcome

The surgery took 85 minutes without any events. The patient developed a mild ileus during the postoperative period and left hospital one week after the procedure. The latest follow-up took place 13 months after this episode, and the patient remains asymptomatic.