Laparoscopic ileocecal resection for Crohn's disease

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Laparoscopic ileocecal resection for Crohn's disease

Authors

J Leroy, J Marescaux

Keywords

Crohn's disease,Crohn,ileocaecal resection,laparoscopy

Media type

Surgical video

Duration

07'00''

Publication

2004-11

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E-publication

WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-vd01en1570.htm

Laparoscopic ileocecal resection for Crohn's disease

1. Trocar placement 00'02''

This video will demonstrate laparoscopic ileocecal resection. The case is that of a 51-year-old male patient with ileocecal Crohn’s disease. The patient is placed supine, and the optical trocar is inserted into the para-umbilical area. Initial laparoscopic exploration is performed. A further trocar is inserted into the epigastric region for the right hand of the surgeon. A suprapubic trocar is inserted as the left-hand operative port.

2. Exposure 00'38''

These abdominal wall adhesions signify previous inflammation and need to be divided in order to achieve adequate exposure. This is done using monopolar scissors, which help maintain hemostasis simultaneously. The greater omentum is then retracted superiorly away from the pelvis. The transverse colon is then also reflected. The slight Trendelenburg position helps maintain the exposure. Now to the ascending colon. This patient has had ileocecal Crohn’s disease for some time and has developed a stenosis in this area. There are signs of previous inflammation as evident. The bowel is now gently manipulated in order to identify the terminal ileum and ileocecal junction. The small bowel is carefully followed caudally as shown. Now we come more distally onto the ileum. And this is the terminal ileum and ileocecal junction. As evident, there are some adhesions to the bowel in this area.

3. Ileo-caecal resection 02'22''

Now to the resection. A further trocar is inserted into the left iliac fossa.

4. Small bowel division 02'34''

We start with the division of the ileum. The linear stapler is introduced and the small bowel is divided.

5. Mesenteric division 02'41''

The mesentery is divided using the Ligasure coagulation device. The dissection is now continued in order to isolate the ileocecal junction. The Ligasure device is useful for this as it is able to adequately control any bleeding from the small vessels in the tissue. The posterior attachments are divided as shown. Blunt dissection is used to open up the plane posterior to the cecum. Now to the medial aspect in the same manner. The mesocolon is dissected in order to accommodate the linear stapler. The bowel is cleared of any pericolic fat in preparation for division. The linear stapler is then introduced and fired to divide the ascending colon.

6. Ascending colon division 04'07''

This usually takes 2 loads. The remaining lateral attachment is now freed. This is again performed using the Ligasure device. We see the ureter here which is peristalting and therefore not damaged. The resection specimen is now completely free. We now need to obtain adequate mobility of the bowel in order to perform the anastomosis. The hepatic flexure is stuck to the gallbladder and these adhesions need to be divided before a tension-free anastomosis can be made.

7. Anastomosis 05'28''

Once adequate bowel length is obtained, the small bowel and colon are placed adjacent to each other, ensuring that there is no twisting. A stitch is then placed prior to formation of the anastomosis. This is repeated in another position in order to maintain the parallel orientation of the bowel. These sutures also act as markers during the insertion of the linear stapler. The suprapubic trocar site is extended and the specimen is retrieved through a wound protector.

8. Specimen extraction 05'59''

The 2 pieces of bowel are brought close to the suprapubic site and the anastomosis is performed through the wound using a linear stapler. This is the end of the operation.