Patients are placed in a modied lithotomy position, ensuring that the legs and arms are positioned appropriately to avoid nerve injury. The patient’s arms should both be tucked by their sides, with the use of sleds if needed for larger patients. In order to overcome the steep Trendelenburg positioning, a bean bag may be placed under­neath the patient, the chest may be taped to the table, or anti-sliding padding can be used. The lithotomy position is important so access to the anus is maintained.

The basics steps of laparoscopic colectomy for CD follow similar principles to those described in the chapters on laparoscopic left and sigmoid colectomy for benign (Chap. 3) and malignant disease (Chap. 17). In cases of abscess and stula with inammatory bowel disease, and similar to some complex diverticular disease, there are several operative steps that are helpful.

Many of these cases are re-operative in nature. Even so, we start with a sub- umbilical cutdown to insert a Hasson balloon port. This commonly is quite straightforward. If there are adhesions or concerns of adherent intestine, a lateral 5mm visual port is inserted, away from the area of the pathology. This guides placement of a second port which allows adhesiolysis and insertion of additional ports as required.

Once the small bowel loops have been separated, the colon can be evaluated. The decision of whether the mesentery or bowel is mobilized rst really depends on what step will facilitate dissection of the diseased segment most safely and effec­tively. Oftentimes, the best strategy is to start by mobilizing the bowel proximal to the pathology in order to dene the correct anatomical planes. This will help iden­tify anatomic landmarks and guide the dissection safely toward the diseased seg­ments and associated phlegmons, abscess cavities, and/or stulas. This dissection will lead next to taking down colovesical, colovaginal stulas, or even left lower quadrant cutaneous stulas. These are transected with a combination of sharp dis­section with scissors and blunt dissection using a Maryland or bowel grasper. For those who like energy devices for dissection, these are particularly unsuitable in stula and abscess cases, as the tissues are often so thickened that the energy devices cannot be closed effectively. When a pericolonic abscess cavity is unroofed, a suc­tion device is immediately positioned into the cavity to aspirate out all pus before it contaminates the abdomen. The goal at this stage is simply to control and minimize spillage of purulence. The use of monopolar cautery should be minimized in order to avoid inadvertent burn injury to the bowel. Sponges can be very helpful to achieve hemostasis as well as to provide effective bowel retraction. Frequently ovaries, fal­lopian tubes, or the appendix may be adherent to the inammatory phlegmon or abscess and must be carefully separated. If the appendix is involved, it is removed as per routine. Once the pathology and anatomy have been fully dened, the entire small bowel should be examined for disease, as described above.

With regards to minimally invasive approach to colectomy in patients with CD, despite a paucity of contemporary studies on this topic, older studies have demon­strated laparoscopy to be safe and feasible when performed at centers of expertise. A single institutional experience was described by Holubar and colleagues identify­ing a total of 92 patients with CD undergoing minimal invasive colectomy from 1997 to 2008 [22]. Procedures included 43 total colectomies, 17 subtotal colecto­mies, and 32 segmental colectomies. Overall, straight laparoscopy was used in 57% of cases and 43% were hand-assisted with no signicant difference in operative times between lap- and hand-assisted groups. The rate of conversion to open lapa­rotomy was 16%, and only small bowel disease predicted conversion (OR 7 (1.6–

35)). Conversion was not associated with increased length of hospital stay or postoperative complications. Overall postoperative length of stay was 5 (4–7) days with a 34% rate of early postoperative complications. Only perianal disease pre­dicted complications after multivariate analysis (OR 2.6 (1.0–6.6)).