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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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232 Atlas of Gastrointestinal Surgery: The Small Bowel
Ascending
colon
The remaining ileocolic mesentery is divided
with a Ligasure or harmonic scalpel intro-
duced through the left port (6).
Ileocolic vessels
(divided)
Ileocolic
mesentery
Terminal
ileum
6
Laparoscopic Ileocecal Resection for Primary Occurrence of Crohn’s Disease 233
Abdominal wall
7
Ascending
colon
Cecum
Mesentery
Terminal
ileum
Once mobilization of the terminal ileum,
cecum, and ascending colon is complete, the
abdomen is irrigated and evaluated for hemostasis.
A laparoscopic Babcock clamp is placed on the cecum. The pneumoperitoneum is released and a 4-cm midline peri-umbil-
ical incision is made. A wound protector is placed in this midline incision, and the right colon is removed by advancing
the laparoscopic Babcock clamp to the midline wound and grasping the bowel with a handheld Babcock clamp (7). The
bowel should be easily retrieved through the midline wound. However, if this is not possible due to thickened mesentery,
the wound may need to be enlarged. The terminal ileum and the proximal ascending colon are divided extracorporally.
Only a 2- or 3-cm margin of normal bowel is necessary for a Crohn’s disease resection.
Either a hand-sewn or stapled anastomosis can be performed. For a hand-sewn ileocolic anastomosis, it is important to
orient the mesentery so that the mesenteric defect can be closed upon completion of the anastomosis.
234 Atlas of Gastrointestinal Surgery: The Small Bowel
The anastomosis is per-
End-to-end
anastomosis
Ileum
formed in an end-to-end
fashion with an inner con-
tinuous layer of 3-0 syn-
thetic absorbable suture mate-
rial, and an outer layer of 3-0
silk Lembert sutures (8).
Proximal
ascending colon
8
The mesenteric defect
is closed with a 3-0
Ascending
colon
absorbable suture (9).
Mesenteric
defect closed
Ileum
9
Ascending
colon
Laparoscopic Ileocecal Resection for Primary Occurrence of Crohn’s Disease 235
Alternative hand-sewn techniques include a side-to-
end (10) or a side-to-side anastomosis (11).
Ileum
Side-to-end
anastomosis
The abdomen is copiously irrigated
with antibiotic-containing solution. The
fascial defects at the port sites are closed
with 2-0 absorbable sutures prior to clo-
sure of the midline incision. The midline
10
Ascending
colon
Ileum
fascia is closed with non-absorbable inter-
rupted sutures, and the skin is closed with
a subcuticular stitch.
11
Side-to-side
anastomosis
Ileocolic Resection for
Recurrent Crohn’s Disease
Operative Indications
Crohn’s disease is an idiopathic inflammatory disease of the gastrointestinal tract that can involve any segment along the entire
gut, but most commonly affects the distal small bowel. The peak incidence is in the third decade, the etiology is unknown,
and it affects men and women equally. The most common pattern of disease at initial presentation is involvement of the ter-
minal ileum and proximal colon. The vast majority of these patients will eventually require surgical resection, with ileocolic
anastomosis. Following surgery, when patients are followed long-term, the majority will recur, generally in the ileum just prox-
imal to the first ileocolic anastomosis (1). Many patients who recur will develop symptoms requiring a second resection.
Previous
ileocolic
anastomosis
Ascending
colon
1
Fat
wrapping
Inflamed distal ileum
Ileocolic Resection for Recurrent Crohn’s Disease 237
Operative Technique
The patient is explored through the original incision, which generally is a mid-
line incision. Often a patient with Crohn’s disease has surprisingly few adhe-
sions, even after multiple laparotomies. The entire gastrointestinal tract is
examined. Crohn’s disease has been described in the esophagus, the stom-
ach, the duodenum, and the entire small and large bowel. However, in the
most common presenting pattern, the disease is limited to a recurrence at the
ileocolic anastomosis (1), following a previous side-to-end ileocolostomy.
There is minimal involvement of the colon at the anastomosis; the ileum is
involved for several inches.
The ascending colon is mobilized out of the retroperitoneum. The ascending colon is divided with a linear stapler 3 or
4 cm beyond the gross disease at the ileocolic anastomosis. The distal ileum is divided with a linear stapler 3 or 4 cm
proximal to the gross disease recurrence in the distal ileum (2). Studies have demonstrated that it is not necessary, nor of
any benefit, to take wide margins of normal bowel around a diseased segment. Recurrence rates are identical with wide or
narrow margins, and if large segments of normal bowel are removed, nutritional problems are more likely to develop.
Ascending
colon
Distal
Mesentery
ileum
Recurrence of Crohnʼs disease at ileocolic anastomosis
2
238 Atlas of Gastrointestinal Surgery: The Small Bowel
Distal ileum
Colon
Mesentery
3
The thickened mesentery to the diseased
segment of ileum and colon is divided between
Kelly clamps, and ligated with 2-0 silks. After
the specimen is removed from the operative
field, the end of the ileal staple line is closed
with a row of interrupted 3-0 silk Lembert
sutures. A new side-to-end ileo-ascending
colostomy is performed in two layers; an inner
continuous layer of 3-0 synthetic absorbable
suture material, and an outer interrupted layer of
3-0 silk Lembert sutures (3). After the anasto-
mosis has been completed, the rent in the
mesentery is closed with either interrupted or
continuous sutures (4). The abdomen is copi-
ously irrigated with an antibiotic-containing solu-
tion and closed.
Side-to-end
ileocolic anastomosis
4
Strictureplasty for Crohn’s Disease
Operative Indications
Crohn’s disease is an idiopathic inflammatory
disease most commonly presenting with
involvement of the terminal ileum and prox-
imal colon. However, the disease can
involve segments along the entire gastroin-
testinal tract, and in some instances there
may be multiple small segments of involve-
ment (1) with skip areas in between. Many
patients with Crohn’s disease require several
exploratory laparotomies and bowel resections.
Patients are always at risk, after several resections, of hav-
ing insufficient bowel length to maintain satisfactory nutrition. When
the pattern of disease is multiple short areas of involvement of the small
Strictured
small bowel
Fat wrapping
Mesentery
1
bowel, strictureplasty is an ideal alternative to multiple resections.
240 Atlas of Gastrointestinal Surgery: The Small Bowel
Operative Technique
The patient is explored through a midline abdominal incision. The entire length
of the bowel is examined for evidence of Crohn’s disease. Even though patients
might have had prior laparotomies for Crohn’s disease, often there are surpris-
ingly few adhesions, and those present are easily lysed.
When short segments of disease are identified, the
strictured lumen can be evaluated by palpation (2).
Stricture
opened
longitudinally
2
If a tight stricture is present, it is iso-
3
lated between linen-shod
clamps and opened in a
longitudinal fashion
using the electro-
cautery (3).
Strictureplasty for Crohn’s Disease 241
Closed transversely
The enterotomy is then closed in a transverse fashion utilizing
a one-layer Gambee suture performed with 3-0 silk (4).
4
The suture passes from the outside in, through the full thickness
of the bowel wall, and then from the inside out, just
through the mucosa on the same side. It is then passed
just through the mucosa, from the outside in, on the
opposite side and then from the inside out, through
the entire thickness of bowel (5). Two or three
Gambee sutures are placed starting at each lateral mar-
gin and secured. Then, the remaining Gambee sutures
are all placed prior to securing them. This results in a secure
5
one-layer anastomosis that ensures inversion of the mucosa (6).
Essentially this Heineke–Mikulicz strictureplasty results in a short-
ening, but a widening, of the section of bowel that contains the
stricture (7). This strictureplasty obviously removes the point of
partial intestinal obstruction without sacrificing any normal
bowel, as would occur if a resection were
6 7
Gambee suture
performed. Multiple strictureplas-
ties can be performed at the
time of laparotomy.
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