HOW I DO IT
|Year : 2020 | Volume
| Issue : 1 | Page : 90-93
Laparoscopic redo surgery in recurrent ileocolic Crohn's disease: A standardised technique
Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust; Faculty of Science, University of Portsmouth, Portsmouth, England, United Kingdom,
|Date of Submission||07-Jun-2018|
|Date of Acceptance||26-Jul-2018|
|Date of Web Publication||20-Dec-2019|
Mr. Valerio Celentano
Portsmouth Hospitals NHS Trust, Portsmouth, England, United Kingdom. University of Portsmouth, Portsmouth
Source of Support: None, Conflict of Interest: None
Background: Despite many advances in the medical management of Crohn's disease (CD), there is still a significant risk of surgical resection for lack of response to medical management or complications during the lifetime of a patient. Laparoscopic surgery offers short-term benefits such as decreased pain, lower wound complication rates, earlier resumption of diet and bowel function, better cosmesis and shorter hospital stays, while reduced post-operative adhesions and lower incisional hernia rate may represent long-term benefits.
Methods: A modular, standardised laparoscopic approach can be applied to safely perform laparoscopic redo surgery in the hostile setting of the recurrent CD and to facilitate teaching and training of these advanced procedures.
Results: Laparoscopic surgery in CD can be particularly challenging due to multifocal disease with extensive inflammation and a thickened mesentery, the potential for abscesses, fistulas and phlegmons and high conversion rates have been reported in reoperative surgery for recurrent CD with abscesses and adhesions representing the main reasons for conversion.
Conclusions: A standardised laparoscopic approach for redo surgery in recurrent CD has been described. Multidisciplinary management of CD is essential and bowel preservation must be the priority.
Keywords: Anastomotic recurrence, Crohn's disease, ileocolic resection, laparoscopic surgery, redo surgery
|How to cite this article:|
Celentano V. Laparoscopic redo surgery in recurrent ileocolic Crohn's disease: A standardised technique. J Min Access Surg 2020;16:90-3
| ¤ Introduction|| |
Despite many advances in the medical management of Crohn's disease (CD), there is still a significant risk of surgical resection for lack of response to medical management or complications during the lifetime of a patient. Over 80% of patients diagnosed with primary ileocolic CD have a surgical resection within 10 years of their diagnosis. Of these, 30%–50% will have symptomatic recurrence of disease during the first 5 years and 50%–80% by 10 years after surgery. Approximately more than 30% of patients undergoing surgery for CD are likely to need further operations within 10–15 years for recurrence commonly occurring at the anastomotic site or in the neoterminal ileum.
When compared with traditional open surgery, laparoscopy offers well-described short-term benefits such as decreased pain, lower wound complication rates, improved pulmonary function, earlier resumption of diet and bowel function, better cosmesis and shorter hospital stays. Reduced formation of post-operative adhesions and lower incisional hernia rate may represent a long-term benefit particularly appealing in this young group of patients who is at significant risk of multiple surgeries.
Laparoscopic surgery in CD can be particularly challenging due to multifocal disease with extensive inflammation and a thickened mesentery, the potential for abscesses, fistulas and phlegmons and lack of tactile feedback potentially limiting the identification of occult disease. High conversion rates have been reported in reoperative surgery for a recurrent CD with abscesses and adhesions representing the main reasons for conversion. A modular standardised laparoscopic approach can be applied to safely perform these advanced cases and facilitate teaching and training.
| ¤ Pre-Operative Study|| |
Multidisciplinary management of CD is essential, and operative indication is discussed at inflammatory bowel disease multidisciplinary team meetings. Bowel preservation is the key in CD surgery and pre-operative mapping of the disease is mandatory with small bowel ultrasound, magnetic resonance imaging enterogram and selective use of ileocolonoscopy. The selection of patients for early surgery versus persistent endoscopic dilatation has been previously reported, with proximal bowel dilatation on radiological imaging, long interval from previous abdominal surgery and long and symptomatic rather than short and incidental strictures representing independent factors associated with the requirement for surgical resection.
Discontinuation of pre-operative immunosuppressors, steroids and biologics is tailored to the individual patient taking into account the severity of the symptoms, the nutritional status and comorbidities, the extent of disease and the previous resections. Ureteric stents are rarely needed and inserted after induction of general anaesthetics, with indications represented by reoperative pelvic surgery and abscesses or phlegmons along the paracolic gutter. Pre-operative stoma care counselling and sitting for stoma are mandatory in CD patients who have a higher risk of anastomotic complications, and who might have significant previous scarring of the abdominal wall, making siting of the stoma challenging. The surgical team must review the previous operating notes focusing on configuration, site and number of previous anastomosis and strictureplasties, height of previous vascular ligations and extent of previous resections and flexures mobilisation.
| ¤ Surgical Technique|| |
The patient is placed in modified Lloyd-Davies position, which may prove useful not only for accessing the perineum for endoscopic assessment of the large bowel but also in case of unexpected colonic involvement found at laparoscopy, such as undiagnosed ileosigmoid fistula with need for simultaneous nerve sparing left-sided colonic resection and transanal stapled anastomosis, or even in case mobilisation of the splenic flexure is needed, which is rarely necessary to allow a tension-free anastomosis when long segments of proximal colon have been resected in patients with multiple previous ileocolic resections.
Mechanical bowel preparation usually consists of a pre-operative phosphate enema, the urinary bladder is catheterised and intermittent pneumatic compression is applied for deep vein thrombosis prophylaxis. In patients with bowel obstruction, the use of a nasogastric or orogastric tube might be useful to decompress the stomach and small bowel and is usually removed in recovery. Patients receive a single dose of prophylactic antibiotics according to hospital's protocol and are routinely enrolled in an enhanced recovery pathway after surgery preferring local anaesthetic wound infiltration over spinal or epidural techniques.
The sites of previous abdominal incisions are marked and the first trocar is inserted through an open Hasson technique away from the midline, in the left lower quadrant lateral to the rectus, two fingerbreadths superior and medial to the left superior anterior iliac spine which is easily palpated. Alternatively, an optical trocar access in the left upper quadrant may be utilised. In patients with previous midline laparotomies, we avoid inserting the first trocar on the midline where adhesions may be encountered with a high risk of inadvertent enterotomies. The use of a 10-mm balloon blunt tip trocar as first port minimises the risk of injury and prevents loss of pneumoperitoneum. Further ports are inserted under direct vision as shown in [Figure 1].
|Figure 1: Standardised placement of operating trocars for redo laparoscopic ileocolic resection for recurrent Crohn's disease|
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The abdominal cavity is inspected and preliminary division of adhesions is often necessary. For this reason, the author prefers to always have available a 30° 5 mm laparoscope, so that additional 5-mm trocars can be inserted at a point of convenience free from adhesions in the abdominal cavity with the laparoscope easily moved between the operating ports to obtain the best possible angle to facilitate adhesiolysis. Cold sharp dissection with laparoscopic scissors is ideal, avoiding transmission of energy and the use of diathermy to minimise the risk of inadvertent bowel injury, which may prove dramatic in patients with several previous surgeries and at risk of short-bowel syndrome. The pneumoperitoneum also facilitates the dissection of these adhesions, which are usually expected in between the omentum and the abdominal wall and in the right iliac fossa where the inflammatory process often occurs. Following the division of adhesions a complete exploration of the peritoneal cavity is performed and the entire length of the bowel is run with atraumatic forceps with a 'hand over hand' technique to ensure no lesion has been missed in the pre-operative workup. While all strictures must be address also with the use of strictureplasties, non-obstructing and non-haemorrhaging bowel may be left and treated medically.
Usually, the dilated bowel can be followed till the anastomosis and the full small bowel can be assessed after positive identification of the Treitz ligament. Other sites of disease can be recognised and the length of the remaining bowel estimated. Manipulation of the small bowel needs to be extremely careful, avoiding grasping the inflamed, thickened and oedematus Crohn's mesentery which easily bleeds resulting in devascularisation of small bowel segments. Closed instruments are preferred where possible. Care must be taken not to inadvertently enter the mesentery while dividing the omental adhesion often wrapping the previous anastomosis. For the initial setting, the patient is placed in the reversed Trendelenburg position with the left-sided tilted down. The omentum is retracted cranially over the upper compartment and the transverse colon is exposed with the small bowel moved to the left side to expose the duodenum.
This is followed by a complete mobilisation of the terminal ileum and right colon and hepatic flexure, with mobilisation of the small bowel mesentery that must proceed up to the duodenum. The recurrence is usually at the ileocolic anastomosis and that area is approached last, particularly in case of residual abscess, preferring a medial to lateral approach with a retrocolic window created on top of the duodenum. Occasionally, placing a 5 mm camera through the suprapubic port can give a very good view of the phlegmon and retroperitoneal structures allowing a safer dissection. Bleeding is not infrequent due to a friable and thickened mesentery and even if this might be controlled with hemolocks clips or endoloop application, laparoscopic suturing skills are essential.
Medial to lateral, sub-ileal, lateral to medial and transverse colon 'top to down' are the four main approaches described for bowel mobilisation in the right hemicolectomy surgery [Figure 2], and the surgeon must be familiar with all of them, as they can all prove useful in re-operational CD surgery. A lateral to medial approach is often advocated in laparoscopic redo CD surgery, and allows satisfactorily mobilisation of the ileocolic segment for an extracorporeal division, while a 'top to down' transverse colon first approach in Trendelenburg position, might allow identification of the retroperitoneal structures from above in obese patients or when dilated bowel obscures the identification of the duodenum, occasionally involved in preoperatively missed coloduodenal fistulas. When present, the management of internal fistulas is decided according to the type of involved structures and the presence or absence of CD on the intestinal segment secondarily affected by the fistula with combined resection proposed in patients with ileocolonic CD and associated CD on the 'receiving' intestinal segment (e.g., colonic or jejunal CD), whereas suture of the fistula is preferred in cases presenting no CD on the 'receiving' intestinal segment. An air-water leak test by on-table flexible sigmoidoscopy might prove helpful in patients with ileosigmoid fistula.
|Figure 2: Four different approaches for the right hemicolectomy. (A) Medial to lateral; (B) lateral to medial; (C) sub-ileal: (D) top to down transverse colon first|
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When adequate mobilisation has been obtained, the bowel is exteriorised through a 4–5 cm midline incision extending the periumbilical port site, which may need to be extended to exteriorise larger terminal ileal phlegmons. When transverse incisions have been previously performed, their use as extraction site is preferred if possible, despite recognising that transverse incisions may compromise future stoma sites and should not be used in the primary ileocolic CD. This provides excellent exposure of the usually thickened mesentery, which is systematically divided using an overlapping Kocher clamp technique after wound protection. Despite vessel sealing devices being theoretically adequate to control large blood vessels, the author prefers to control the friable CD mesentery with transfixion sutures. After transecting the bowel ends at a 2 cm distance from a palpable diseased mesenteric margin, a side to side ileo-colic anastomosis is usually fashioned and after confirming that the anastomosis is widely patent, the bowel is gently pushed back into the abdominal cavity. The author prefers a iso-peristaltic two layer hand-sewn anastomosis. The isoperistaltic anastomosis is preferred for an earlier return of the bowel function and for an easier endoscopic dilatation option if recurrence occurs. Moreover, a side-to-side anastomosis might provide a better blood supply to the anastomotic segments and a wider anastomotic lumen, leading to a reduced rate of anastomotic disease recurrence. Following the division of the proximal and distal bowel ends with a linear cutting stapler and oversewing the stapler lines, the neoterminal ileum and colon are approximated with an outer layer of interrupted 4/0 monofilament polydioxanone re-adsorbable suture and a full thickness continuous inner layer is then fashioned, with an anterior Connell suture pattern. A second outer layer of interrupted sutures is also completed on the anterior aspect of the anastomosis, and the mesenteric defects are closed with sutures, or where possible with an omental wrap technique. Re-laparoscopy is finally performed to ensure haemostasis and evaluate the need for lavage. Intra-abdominal drains are not routinely used.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]