Laparoscopic ileocecal resection for Crohn's disease

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Laparoscopic ileocecal resection for Crohn's disease

Authors

J Leroy, J Marescaux

Keywords

ileocecal resection,Crohn's disease

Media type

Surgical video

Duration

18'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1575e.htm

Laparoscopic ileocecal resection for Crohn's disease

1. Patient and trocar placement 00'15''

The patient’s BMI is around 23; in other words, it’s not an obese patient. The patient is placed in the Lloyd-Davis modified position, with 2 arms alongside the body, the 1st assistant to the surgeon’s right and lateral to the patient’s left shoulder and the nurse is standing between the patient’s legs with the instrumentation and table ready. The laparoscopic unit is on the right side of the patient. I will use 4 trocars but we could do the operation with 3 trocars. This is the optical port. I have positioned the trocars as for appendectomy. My 2nd trocar is positioned in the suprapubic area, not far from the anterior superior iliac spine on the midline. The right hand-working trocar is on the left of the patient, a little above the anterior superior iliac spine laterally to the epigastric vessels. I have added another trocar, placed medially or in the left subcostal area to expose and retract if necessary.

2. Exploration and exposure 01'36''

The 1st step is to explore the abdominal cavity. No adhesions were found to the anterior abdominal wall or into the abdominal cavity. There is the liver, the stomach and we have a good exposure to do a panoramic exploration rapidly. I want to put the omentum above the transverse colon in the subphrenic area to expose the mesocolon. You see that the cecum is falling. The ileocecum is here but in Crohn’s disease, you have to explore completely. The last loop is a bit rigid, which is due to the stenosis. In this area, we have a fixation of the mesentery to the mesentery and we have inflammatory adhesion of the last ileal loop. There’s a small fixation to the sigmoid here and it could be a fistula. We’ll see better once we have divided. I don’t touch the sigmoid. I’ll complete my exploration to see if there is anything else along the small bowel and to see if there is no other duodenojejunal junction. My camera is still. I come in the field of the camera. I have a ring because we have a wider field. If I zoom too much, I will have less field and therefore not the same view. The loop is very long. I am on the duodenojejunal junction. Now I have to put the small bowel more to the left and so I use some more lateral tilt and more Trendelenburg.

3. Ileomesenteric division 04'51''

I have to resect 30-40cm of small bowel. I will resect this. I’ll cut the colon at this place. I have to resect the ileum. For better exposure, I’ll use a forceps. I use the bipolar for cutting. The Ligasure has some difficulty when the mesentery is thick like this. It’s not easy to divide the mesentery. I think we have to dissect the vessels more. These are nodes.

4. Colon dissection and division 07'32''

Now I’m freeing lateral attachments. First I’ll not divide the distal colon immediately as for cancer because I’ll do the anastomosis outside through the suprapubic incision and I’ll do a palpation of the colon with my finger outside to check if it’s the right place for the anastomosis. I want to free posterior anteriorly to Toldt’s fascia. I won’t divide the vessels. I’ll complete this freeing by dividing the transverse mesocolon. In this case, we can keep the omentum because it’s not a cancer. This is the sigmoid. Even if I have to resect the sigmoid, I’ll do it once I have done my freeing. This is the small bowel. I’ll divide the peritoneum. This is a good sealing. The color looks good.

5. Anastomosis 11'23''

We have to remove this part of the bowel first. For that, I’ll use a suprapubic incision. I’m using an Endo-GIA 60. We make sure the colon is airtight. We extract easily and rapidly the colon through 4.5 sized lens incision and I do 2 seromucosal stitches on the small sutures. The colon is very compliant and you have the anastomosis that is covered by continuous sutures of Polysorb. I don’t close the gap as is usual. Now we have cleaned the abdominal cavity and this looks perfect.