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244
A. J. Greenstein and B. Salky
division across the stulous tract with resection of only the diseased ileocolic segment or en bloc resection. While simple ileosigmoid stulae can often be approached
laparoscopically, stulae low in the sigmoid colon or more distal in the region of the
rectouterine or rectovesical pouch may require a hand-assisted or open approach.
In the event of a simple ileosigmoid stula, after mobilization of the right colon
and sigmoid, it should be possible to lift the Crohn’s mass and sigmoid anteriorly
and superiorly in order to identify the tract from the ileum to the sigmoid. After it
has been dissected out and thinned out as much as possible, it should be possible to
laparoscopically place an endoscopic linear stapler loaded with a 60-mm-long
purple, green, or black load through an appropriately sized port and staple across the
brous tract (Figs.16.2a, b1, c1 and16.3a–c). The sigmoid will fall gently aside
leaving the right colon and ileum which can then be resected and anastomosed.
Complex ileosigmoid stulae which require double resection (Fig.16.2a, b2, c2)
may be able to be performed by a pure laparoscopic approach, but often their
complexity may require conversion. Again, we recommend trying to mobilize as
much as possible laparoscopically or try hand-assisted techniques prior to converting
as this can reduce the size of the incision and still greatly benet the patient.
a
b1
c1
Fig. 16.2 (a) Ileosigmoid stula. (b1, b2) Division across the stulous tract with resection of the
diseased ileocolic segment only. (c1, c2) En bloc ileosigmoid stula resection with double
anastomosis
c2
b2
16 Advanced Laparoscopic Right Colectomy Techniques forCrohn’s…
245
a
b
c
Fig. 16.3 (a–c) Crohn’s ileosigmoid stula. The endoscopic stapler is used to transect across the
stula with ileocolic resection and preservation of the sigmoid
Difficult Crohn’s Mesentery
As discussed previously, the friable and thickened Crohn’s mesentery presents a
unique challenge, as often the standard energy devices are not adequate to seal the
vessels. For this reason, we recommend mobilizing the diseased bowel rst to lift the
mesentery off the retroperitoneum prior to mesenteric division. Once the diseased
bowel is mobilized, a decision is made whether to transect the mesentery intracorporeally or extracorporeally. If the mesentery appears thin and pliable and amenable to
division with an energy device, laparoscopic transection can be attempted. Additionally,
the mesentery further away from the bowel wall may be thinner and more amenable
to standard division with an energy device. In these situations, a high ligation and
mesenteric division similar to that for oncologic resections is recommended. There
are many devices well equipped to deal with intracorporeal mesenteric division. These
include ultrasonic, bipolar, mechanical (staplers and clips), and monopolar electric
devices. All can be utilized to divide the mesentery and control bleeding. When these
fail, the surgeon needs to be ready with a backup plan which may include laparoscopic
suturing or temporary pressure control and conversion to open.
If the mesentery appears to be very bulky and is deemed to be at risk for bleeding
after transection with a bipolar device, then it may be safer to perform mesenteric
division in an extracorporeal fashion. By mobilizing the diseased and adjacent normal bowel, at least the extraction incision will be smaller than if approached open to
start. When in doubt, and if there are questions about vascular control, performing
this portion of the procedure in an open fashion is safer. When ready to extract and
divide mesentery, we make a periumbilical incision, place a wound protector, and
246
A. J. Greenstein and B. Salky
exteriorize the diseased bowel. Occasionally, the Crohn’s mass is too large to t
through the small extraction site, so the skin incision may need to be enlarged. It is
critical that one maintains control of the proximal portion of the mesenteric vessels
during exteriorizing the bowel and mesenteric transection in order to reduce arterial
bleeding and/or hematoma formation. After exteriorization, one can place a soft
bowel clamp toward the root of the mesentery and use the bipolar device on the more
distal portion of the vessel. Even with this technique, it is not uncommon to require
multiple 2-0 Vicryl sutures in a gure-of-eight fashion or horizontal mattress fashion
in order to control bleeding vessels after attempted control with an energy device or
even clamp and tie technique. With the specimen already exteriorized, resection and
anastomosis will follow mesenteric transection through this incision.
Ileocolonic Reconstruction
After the mesentery has been divided intracorporeally, one can then decide whether
to make an intracorporeal or extracorporeal anastomosis. In addition to the patient’s
pathology, the surgeon’s comfort and prociency plays a role in this decision, and
we will outline both approaches in the next two sections. The benets of an intracorporeal anastomosis include but are not limited to the need for more limited mobilization of the bowel as it does not need to be exteriorized until after division. Ability
to place the extraction site at any location, preferably Pfannenstiel or off midline/
planned stoma site, as this is associated with decreased pain and decreased subsequent hernia formation.
Intracorporeal Anastomosis
Our preferred intracorporeal ileocolic anastomotic technique is as follows [14].
Once the mesentery and specimen have been divided, the two ends of the bowel are
aligned in an isoperistaltic fashion (antiperistaltic is another option), after the mesentery is visualized at its base. This is an important maneuver to ensure there is no
twisting of the anastomosis. If this step is followed, it is impossible to twist the
anastomosis. Stay sutures are often placed to help align the bowel and to help with
manipulation during stapler placement. Once the intestine is aligned, an enterotomy
is made in both the proximal and distal bowel. We prefer to do this with cutting current electrocautery, but ultrasonic devices can be used. If the intestine is dilated
from obstruction, a laparoscopic “bulldog” clamp can be placed on the proximal
side at least 10 cm up from the planned anastomosis to prevent spillage. Often,
however, the pressure of the pneumoperitoneum is enough to prevent enteric spillage. Once the enterotomies are made, an endoscopic linear stapler is placed into
each limb of the intestine and red to create the side-to-side anastomosis. A 60mm
load is preferred but a 45mm is acceptable. We prefer a purple load, but vascular or
thicker loads may be required based on the condition of the bowel and surgeon
preference (Fig.16.4). At this point, the inside staple line is checked for bleeding.
Any bleeding must be controlled now before the common enterotomy is closed. We
16 Advanced Laparoscopic Right Colectomy Techniques forCrohn’s…
Fig. 16.4 Intracorporeal
anastomosis: stapling and
creating of a common
channel
Fig. 16.5 Intracorporeal
anastomosis: suturing
close the common
enterotomy
247
prefer bipolar energy to control bleeding points on the metal staple line, but this can
also be controlled by monopolar cautery, clips or suture ligation.
The options for enterotomy closure are largely dictated by surgeon preference.
We prefer a 2-layer closure with an inner absorbable and outer permanent suture. In
our experience, this is preferably with 2-0 Vicryl for the inner layer and 3-0 Prolene
for the seromuscular outer layer. The use of a single-layer closure, of barbed sutures,
and of stapled closure has all been validated. When starting the rst/inner layer, we
recommend that the surgeon sew away from oneself laparoscopically and toward
oneself in open procedures (Fig.16.5). The reason for this is that it allows the surgeon to place the sutures at right angles to the bowel easier than if sewing toward
oneself. This also ensures that the innermost portion of the common channel is
completely closed. This can often become difcult to see if sewing toward oneself
on the inner layer as that area will have less exposure as the suture progresses closer
to the near corner. As suturing can be perceived as a difcult task, the common
248
ab
cd
A. J. Greenstein and B. Salky
channel can be stapled closed using an endoscopic stapler. However, if a stapler is
used to close the enterotomy, extreme care must be taken to not include the mesentery or to narrow the anastomosis.
Extracorporeal Anastomosis
In order to minimize anastomotic leaks, our preferred approach when performing
an extracorporeal anastomosis is to “oversew” the anastomotic staple lines. After
the specimen has been resected, the end of the ileum is aligned with the proximal
colon in an antiperistaltic side-to-side fashion. We rst lay down a posterior
continuous 3-0 silk back row on the taenia of the colon and adjacent to the
mesentery of the small bowel (Fig. 16.6a). Enterotomies are then made by
e
Figs. 16.6 (a–e) Technique of oversewing the anastomosis. (a) Lying down posterior/back row.
(b) Pulling the mesentery posteriorly. (c) Creating the common channel. (d) Closing the common
enterotomy. (e) Oversewing all staple lines and tucking all corners
16 Advanced Laparoscopic Right Colectomy Techniques forCrohn’s…
excising the anti-mesenteric corners of the staple lines on the bowel. The row of
silk sutures is then pulled posteriorly so as to remove the mesentery away from
the staple line (Fig.16.6b), and a linear stapler (typically 80 mm) is placed to
create the common channel (Fig.16.6c). A second linear stapler load is used to
close the enterotomy (Fig. 16.6d), and then all staple lines are oversewn and
covered with running 3-0 silk suture (Fig.16.6e). For more details and alternative
techniques, please refer to Chap. 14 on options for ileocolonic reconstruction.
249
Pitfalls andTroubleshooting
Entry
Avoid previous scars. Use either optical trocars or open Hasson techniques depending on expertise of the surgeon. After subsequent trocar placement, always look
back at the original trocar and the abdominal wall to make sure a through and
through or occult injury has not occurred. In the unoperated abdomen, a Veress
needle has also been shown to be a safe entry as well.
Adhesiolysis
Use sharp dissection whenever possible. Beware of the “aggressive” assistant.
Traction injuries from graspers are common in laparoscopic surgery. If there is troublesome bleeding during adhesiolysis, it is likely that the wrong surgical plane has
been entered. Stop the dissection and correct the plane of dissection. After adhesiolysis, always go back and visualize the areas lysed to be sure a bowel injury has
not occurred. If there is any suspicion of injury, repair is indicated. If there is any
question, exteriorization of the segment is advised.
Duodenum andRight Ureter
It is critical that these two structures be clearly identied during mobilization of the
right colon. The best plane for proximal transverse colon mobilization is right on the
duodenum, and we advise that a sweeping-blunt technique be used when possible
with minimal energy use. Any injury or potential injury to either of these structures
must be immediately addressed.
Thickened Mesentery
This has been discussed in detail above. Bleeding can be profuse from inamed
mesentery; therefore, suturing skills should be obtained before tackling difcult
mesenteric dissection via minimally invasive techniques. Consider higher ligation
as in cancer cases as the mesentery tends to be thinner in this area compared to
immediately adjacent to the bowel wall. Laparoscopic or open gure of 8 or horizontal mattress sutures placed while the mesentery is compressed and controlled
can get the patient and surgeon out of a difcult situation. Mechanical staplers do
not work well on the thickened mesentery, and in general, they should be avoided
unless the jaws will close easily around the vessels.
250
A. J. Greenstein and B. Salky
Anastomotic Problems
Keeping the anastomotic leak rate low is important. In order to avoid twisting the
anastomosis, the base of the mesentery must be identied and the edge of the mesentery traced up to the cut end of the bowel. At the completion of the anastomosis,
it should look correctly oriented. If there is any doubt as to that, we strongly recommend that the anastomosis be redone.
Postoperative Issues
In general, the patients look well, and they are ambulating the rst evening or certainly the next day. The WBC can be elevated, but it is highly unusual for that to last
more than a day or two. There are some studies that suggest following CRP is a
more predictive value in assessing for postoperative complications such as anastomotic leak. It is not uncommon to have a low-grade temperature for a day or two,
but not more than that. While a little nausea is common, vomiting is not. The abdomen can, of course, be a little tender for the rst day or two, but usually not more
than that. If the patient does not adhere to these clinical parameters, it is likely that
there is something wrong. We have a very low threshold to take the patient back to
the OR for a diagnostic laparoscopy to make sure that the anastomosis is intact. An
early CT of the abdomen in our experience almost never tells the real picture of
what is happening in the abdomen. Additionally, if there is high clinical concern
over the patient’s status, there are very few ndings on CT that absolve the concern
and prevent return to the OR.When returning to the OR, we prefer a laparoscopic
approach to asses for anastomotic leak or occult bowel injury or bleeding as most
can be dealt with in this manner. It is a mistake to wait until the patient is overtly ill
before returning them to the OR.
Ileostomy andConversion
Temporary ileostomies are occasionally needed. Decisions for end or loop stoma
creation should be denitively made preop based on the patient’s overall condition. This is often based on patient-related factors such as nutritional status, lab
values and immunosuppressive medications, and recent weight loss. Occasionally
the decision to create a stoma is made based on intraoperative conditions such as
nding an abscess, dilated/thickened proximal bowel, residual diseased bowel,
and/or the need for double resections. Marking the patient preoperatively is mandatory to avoid the issue of improper stoma creation if the decision is made based
on unplanned operative ndings. We believe that the anastomosis should be perfect in appearance, or it should be revised. We do not divert to compensate for a
suboptimal anastomosis.
The threshold to conversion to open or hand-assist will vary based on the surgeon’s experience and expertise with advanced skills. We strongly believe in preemptive conversion rather than reactive conversion, especially in cases where there
is failure to progress due to difculties identifying the correct anatomical planes of
key landmarks. Prompt conversion will avoid injury and reduce intraabdominal
spillage with associated septic complications.
16 Advanced Laparoscopic Right Colectomy Techniques forCrohn’s…
251
Outcomes
Increasingly, laparoscopic resection has been used to treat patients with Crohn’s
disease and for those requiring reoperative surgery, and this has been validated by
several articles that depict good results. Prospective randomized, retrospective,
database studies and meta-analyses have all shown short- and long-term benets of
laparoscopic surgery in comparison with open surgery. Short-term benets include
reduced morbidity, expedited recovery, and lower cost, while signicant long-term
benets include fewer small bowel obstructions and incisional hernias [6, 15–21].
CD recurrence rates, not surprisingly, are unchanged by laparoscopic surgery. They
are essentially equivalent to that of open surgery and remain high [22, 23]. Please
see Table16.1 for a listing of some of these studies.
Clearly, laparoscopic resections are possible, even likely, in Crohn’s and reoperative surgery given a certain level of expertise. Considering the incidence of recurrent
disease and surgery in these patients, an initial laparoscopic approach is indicated
[24]. There are also several studies that have been published which analyze laparoscopic surgery for recurrent Crohn’s versus primary Crohn’s disease. They essentially demonstrate that laparoscopic surgery can be performed safely on recurrent
patients with minimal difference in postoperative complications in comparison with
primary Crohn’s patients [25–28].
With regard to “oversewing” the anastomosis, a retrospective comparative study
at our institution has revealed that the use of this technique for our Crohn’s patients
led to a signicant reduction in major anastomotic complications– a compilation of
anastomotic leak, intraabdominal abscess, small bowel obstruction, and anastomotic bleed [29]. Even in the setting of acute abscess or phlegmon, if a carefully
constructed anastomosis is created, it is not necessary to create an end ileostomy or
diverting loop ileostomy for these cases. There are currently many retrospective
papers debating the relative merits of different congurations of ileocolic anastomoses– end-to-end, side-to-side– as well as different types of handsewn anastomoses
[30]. A full discussion of this is beyond the scope of this chapter, but there are no
good randomized prospective trials indicating advantage of any one technique [31].
We recommend that the individual surgeon perform the anastomosis that they are
most comfortable with.
As for intracorporeal anastomosis, several papers and meta-analyses have been
published so far stressing the feasibility and safety in colorectal surgery. The use of
intracorporeal anastomosis should lead to the reduction of incision length, allow for
off-midline or Pfannenstiel incisions to decrease postoperative pain, lower incisional hernia rate, and eliminate the need for bowel exteriorization for anastomosis,
which could be particularly difcult in the presence of thick and short mesentery
and involve the risk of bowel torsion [32–34]. There is a decreased wound infection
risk with intracorporeal anastomosis as well, primarily because there is minimal
contamination at the extraction site. All specimens are removed in a bag or with
wound protection, and typically through a Pfannenstiel incision. Our data have
shown a statistically signicant decrease in narcotic use as well [14]. Other studies
252
Table 16.1 Lap vs open ICR for Crohn’s disease
Author
Milsom [20] 2001 60
Maartense
[19]
Lee [6] 2011 1917
Aytac [21] 2012 52
YoungFadok [16]
Bergamaschi
[18]
Lowney [23] 2005 113
Heimann
[24]
Patel [17] 2013 2519
LOS length of hospital stay, RR relative risk
YearN (%Lap) Term Type Short-term results
Short Prospective
(52%
lap)
2006 60 (505
lap)
(34%
lap)
(50%
lap)
2001 66
(50%
lap)
2003 92
(42%
lap)
(56%
lap)
2017 750
(33%
lap)
(N/A)
randomized
Short Prospective
randomized
Short Database
(NSQIP)
Short Case-matched
retrospective
Short Case-matched
retrospective
Retrospective Lap with signicant
Short
and
long
Long Retrospective N/A No signicant
Long Retrospective N/A Hernia rate
Meta-analysis Lap with signicant
Short
and
long
A. J. Greenstein and B. Salky
Lap with signicant
decrease in minor
complications and
signicantly better
lung function
Lap with signicant
decrease in
complications (10%
vs 33%), LOS
(−2days), and costs
Lap with signicant
decrease in major
(0.629) and minor
complications
(0.576), signicant
decrease in LOS
(−1.08days)
No statistical
difference in overall
morbidity and
reoperation rate. Lap
with signicant
decrease LOS
Lap with signicant
decrease in LOS
(−3days) and costs
($3373)
decrease in LOS
(−5.6days) but
longer OR time
(80min)
decrease in
complications (0.71)
Long-term
results
N/A
N/A
N/A
N/A
N/A
No signicant
difference in
5-year
recurrence
(approx 28%)
difference in
5-year
recurrence
higher for open
(10.8%) than lap
(8.4%) but not
signicantly
different
No signicant
difference
recurrence.
Hernia rate
signicantly
lower for lap(RR
=0.24)
16 Advanced Laparoscopic Right Colectomy Techniques forCrohn’s…
Table 16.2 Intracorporeal versus extracorporeal results for ileocolic resection
Author
Grams
[14]
Vignali
[39]
Martinek
[38]
Milone
[37]
Cirocchi
[35]
ICA intracorporeal anastomosis, ECA extracorporeal anastomosis, SSI surgical site infection, LOS
length of hospital stay
Year N (%IC) Term Type
2009 105
(51%)
2017 128
(50%)
2018 453(51%) Short Propensity
2014 512
(56%)
2012 945
(N/A)
Short Retrospective Crohn’s
Case
Short
matched
and
retrospective
long
score
matched
cohort.
Short Propensity
score
matched
case-control
study
Short Meta-
analysis
Patient
characteristics
patients
Obese
patients with
colorectal
disease
Crohn’s and
obese colon
cancer
Colon cancer ICA with
All No
Short-term
results
ICA with
signicantly
less narcotic
usage, LOS,
morbidity
ICA with
signicantly
earlier bowel
function
ICA with
signicantly
lower SSI
rates and less
morbidity
(5.1% vs
12.8%)
signicantly
lower minor
complication
rate 0.63)
signicant
difference in
leak rate and
morbidity
Long-term
results
N/A
ICA with
signicantly
less (8% vs
25%)
incisional
hernia at
2years
N/A
N/A
N/A
253
that have looked at right colonic intracorporeal anastomosis for various indications
with no adverse effect on complications, anastomotic leak, or reoperation rates and
particularly good results appear to be present for intracorporeal anastomosis in the
setting of obesity [14, 35–39]. See Table16.2.
Conclusion
Primary and reoperative surgery in Crohn’s disease is common. The preoperative
evaluation is important so as to have an exact diagnosis of the type and extent of the
disease including mapping of stulas and abscesses. Even if the patient has had
multiple, previous open surgeries, an attempt at laparoscopy is worthwhile for the
patient and will reduce both short- and long-term outcomes. While intracorporeal
anastomosis has several advantages, the technical demand and additional time it
takes to complete laparoscopically has lead thus far to limited widespread usage