Laparoscopic ileocaecal resection in Crohn's disease: right hemicolectomy

This video shows the surgical treatment of a mass in the right iliac fossa in a patient presenting with Crohn’s disease.

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Laparoscopic ileocaecal resection in Crohn's disease: right hemicolectomy

Authors

J Leroy, J Marescaux

Abstract

This video shows the surgical treatment of a mass in the right iliac fossa in a patient presenting with Crohn’s disease.

Classification

complex cases

Keywords

laparoscopy, ileocecal resection, right hemicolectomy, colon, Crohn\'s disease

Media type

Surgical video

Duration

14'00''

Publication

2008-09

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E-publication

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en2305.htm

Laparoscopic ileocaecal resection in Crohn's disease: right hemicolectomy

1. Clinical case presentation 00'17''

This video demonstrates the surgical treatment of a mass in the right iliac fossa in a 40-year-old female patient presenting with Crohn’s disease. Medical treatment failed and surgery was then opted for.

2. Diagnostic laparoscopy 00'27''

We first perform exploration and exposure of the abdominal cavity. A 10mm port is placed using an open laparoscopy technique at umbilical level. At this stage, we can observe the presence of yellowish fluid in the left paracolic region.

3. Exposure 00'46''

Exposure starts with the retraction of the transverse mesocolon and at the level of the root of the mesentery, we can see the presence of multiple lymphadenopathies in keeping with the pathology.

4. Duodenal junction (landmark identification) 01'00''

Our first landmark is the duodenojejunal junction where we performed the exposure by retracting the transverse mesocolon. Once the duodenojejunal junction has been identified, we begin to inspect the region looking for the presence of a stenosis at the ileal level. This leads us to the last 50cm of ileum where we can start to observe the beginning of the inflammatory process situated at the level of the right iliac fossa.

5. Inflammatory mass dissection 02'15''

We begin with blunt dissection of the mass located in the right iliac fossa. This dissection is done with monopolar cautery scissors as the inflammatory process in the right iliac fossa covers the last centimetres of the ileal region and the first 5cm of the ileocaecal region.

6. ‘en bloc’ division 02'40''

Because the dissection cannot be carried out in contact with the mass, we decide to perform an en bloc division. The objective of this operative strategy is to divide the small bowel proximal and distal to the inflammatory site in order to better mobilize the area. Much better traction is achievable as you can see here. The traction exerted by the surgeon’s left hand helps to gently achieve dissection in contact with the peritoneum. As we continue the en bloc resection, we identify the ileocolic vessels, which will be divided using the Ligasure device. The traction exerted by the surgeon’s left hand helps to open the space, tent the vessels and achieve posterior coagulation. Dissection is continued towards the right Toldt’s fascia, thus achieving total freeing of the caecum. Introduction of a 60mm blue linear GIA stapler allows for transection. Mobilization is then continued with retraction of the inflammatory mass allowing for posterior dissection of this mass. The objective is to perform division and dissection of the inflammatory process in contact with the bowel loops in order to make sure the right ureter is protected and preserved. Since there is significant inflammatory process, the presence of bleeding is evident. It can however best be controlled with use of the Ligasure device.

7. Lateral approach 05'33''

Because the medial approach turns out to be very difficult, we switch instead to employing a lateral approach. This starts with freeing the right paracolic gutter using the Ligasure device and continues with division of the posterior attachments of the caecum. Freeing and division always take place anterior to Toldt’s fascia. This plane is chosen in order to preserve the right ureter. We continue now using a lateral posterior approach, by employing medial traction of the specimen in order to complete the dissection and totally free the inflammatory mass that was in the right iliac fossa.

8. Side-to-side anastomosis 07'05''

Once the specimen has been resected, we must restore intestinal continuity. To do so, we apply a traction stitch placed at the ileocolic level which will allow us to perform the side-to-side anastomosis. Once the suture is placed, we perform an enterotomy followed by a similar colotomy at the adjacent portion of colon. This allows the introduction of a 60mm blue linear GIA stapler to perform the side-to-side ileocolic anastomosis. We now need to close the enterotomy sites. To do so, we go to the superior edge of the mechanical suture line and place a second traction suture. Before applying the mechanical suture however, we perform further dissection of the mesentery and mesocolon in order to obtain a better grasp of the bowel. As you can see here, we place the mechanical stapler through the intestinal gap and perform the anisoperistaltic side-to-side anastomosis. The mesenteric gap has been partially closed as you can see. Before we complete the surgery, we have to identify the right ureter. We can see it here running downwards at the paracolic level, posterior to Toldt’s fascia. The specimen will be extracted via a 3 to 4cm length excision located suprapubically. To do this, a plastic extraction bag is used.