Crohn Disease: Surgical Management

David M. Schwartzberg

Stefan D. Holubar

Perioperative Considerations

Managing Crohn patients is a multidisciplinary endeavor that requires close collaboration with the referring an inflammatory bowel disease (IBD) subspecialist gastroenterologist. Understanding the medical management and how that interplays with surgery is critical to decision-making.
- Formulation of a multidisciplinary care team plan
- Thiopurines and biologics, both of which have very long half-lives, may safely be held perioperatively.
- Assessment and active preoperative management by the surgeon of modifiable risk factors such as
  - smoking/nicotine cessation
  - steroids/immunosuppressive medications tapering
  - management of intra-abdominal sepsis with enteral/parenteral antibiotics and percutaneous drains
  - nutritional optimization with exclusive enteral nutrition (Ensure monodiet) or total parental nutrition
  - correction of anemia with iron and B₁₂ infusions, folate, and vitamin C supplementation
- Preoperative stoma education and site marking
- Optimization of present peristomal and enterocutaneous fistula skin
Prior to embarking on any elective Crohn-related surgery, it is important to fully assess the extent of the disease. This may include any or all of the following:
- Endoscopy including colonoscopy/sigmoidoscopy/proctoscopy and esophagogastroduodenoscopy
- Contrast-enhanced cross-sectional small bowel mapping with magnetic resonance enterography, computed tomographic enterography, or fluoroscopic small bowel follow-through
- Ancillary fluoroscopic studies such as water-soluble enema (not barium), sinograms/fistulograms
- Examination under anesthesia
- Thorough review of prior operative and pathology reports
Perioperative measures should include
- Cathartic and oral antibiotic bowel preparation (in the absence of acute small bowel obstruction)
- Parenteral antibiotics at least an hour prior to incision
- Pre-incision venous thromboembolism (VTE) prophylaxis
- With regard to stress-dose steroids, this historic practice has generally been abandoned for several reasons.
  - First, level 1 evidence exists, showing that stress-dose steroids may be safely omitted.
  - Second, in the era of enhanced recovery, patients are typically given intraoperative 8 mg of dexamethasone for prevention of postoperative nausea and vomiting, which is effectively stress dose.

Procedures: Laparoscopic Surgery for Inflammatory Bowel Disease

Palliative loop ileostomy, ileocolic resection, redo ileocolic resection, segmental small bowel or colon resection, total abdominal colectomy, and total proctocolectomy

Patient Positioning

Padded operating room table, arms tucked and padded
Lithotomy with Yellowfins for most cases; consider split leg as well
- Allows for:
  - Perineal access
  - Intraoperative lower endoscopy
  - Stapled end-to-end anastomosis
- Upper lateral leg padding to protect the peroneal nerves
- Foley catheter should not be allowed to fall into the anus and should be secured and passed under the inner thigh.
Patient must be secured to the bed with a Velcro strap or wide silk tape.
If the stoma site is not tattooed (ie, marked with ink), it should be marked with small needle “poke” holes in a circular pattern (as opposed to an “X,” which is more likely to leave a scar if the stoma is omitted).

Sterile Instruments/Equipment

Basic laparotomy tray
- Kocher and Kelly clamps for mesenteric ligation
- Long- and short-needle drivers, Metzenbaum scissors, heavy Mayo scissors, and DeBakey and Adson forceps
- Hand-held electrocautery pencil and Yankauer suction
Basic laparoscopy tray
- Multiple 5-mm atraumatic bowel graspers; 5-mm modified endo-Babcock (preferred)
- 5-mm electrified endoshears with trigger switch (preferred) or foot peddle
Additional equipment
- Wound protector (typical sizes: small, 2.5-6 cm; medium 5-9 cm)
- One 12-mm sleeve without obturator
- Small ¼-in Penrose (or silastic) drain to secure the 12-mm sleeve in the wound protector
  - may also use proprietary rigid wound protector cap
- Two to three 5-mm optical trocars
- 5- or 10-mm high-definition laparoscope, rigid or flexible-tip (preferred) and insufflation tubing
  - Using a 5-mm laparoscope allows for “port hopping,” such that the laparoscope can be placed in any of the ports.
- Preferred: 5-mm electrosurgical vessel sealing device for intracorporeal vessel ligation and also for dealing with thick mesentery extracorporeally
- Optional:
  - Passive (preferred) or active smoke evacuator
  - Laparoscopic suction irrigator (especially in phlegmon pelvic cases)
  - Anti-adhesion barrier (but must not place atop an anastomosis)
Stapled anastomoses (see Chapter 19)
- Traditional Cleveland Clinic method for stapled anastomosis
  - 29, 31 or 33 mm circular stapler for end-to-side ileocolic anastomosis
  - TA-90 gray load to close the common enterotomy after circular stapler is fired
  - Common enterotomy may also be oversewn.
- Alternative method
  - Gastrointestinal anastomosis (GIA)-80 stapler with blue loads for extracorporal resection and anastomosis
  - Endo-GIA if intracorporeal resection or anastomosis
  - TA-60/TX-60 stapler with a blue loads to close the common enterotomy
  - In cases of thick bowel wall, green loads should be used.
  - Note the enterotomy should be measured, and if approaching 6 cm in length, then consider using a TA-90 gray load stapler.
Sutures (with taper needles)

Traditional Method for Mesentery Ligation and Sutured Anastomosis

#1 chromic sutures for interlocking suture ligatures for Crohn mesentery
3-0 absorbable braided suture for the anastomosis: crotch stitch, and for imbrication of the corners and transverse/crossing staple lines
3-0 chromic sutures for stoma maturation
Two running #1 looped absorbable monofilaments for fascial closure
Stainless-steel staples and 4 × 4 gauze, paper tape for skin closure

Alternative Method

Large jaw electrosurgical instrument and supplemental 2-0 absorbable interlocking monofilament suture for mesenteric ligation
3-0 absorbable monofilament for the back, inner, and front wall of the anastomosis; for the crotch stitch; and for imbrication of the corners and transverse/crossing staple lines
- Two packs of 3-0 absorbable braided pop-offs for stoma maturation
Two running 2-0 absorbable monofilaments on a ½-in taper needle for the fascia
4-0 absorbable monofilament and skin glue, without dressings, for the skin

LAPAROSCOPIC TRANSVERSUS ABDOMINIS PREPERITONEAL PLANE BLOCK

Technique

Specific Equipment

Local anesthetic:
- 20-mL liposomal bupivacaine plus 30 mL of 0.5% (or 0.25%) bupivacaine plus 100 mL of injectable saline; increase to 150-200 mL of injectable saline for open cases
Spine needle with low-pressure extension tubing
23-gauge 1.5-in needle (for infiltrating port sites and ostomy/extraction site fascia and skin)
Malleable retractor or other flat metal surface for blunting the spinal needle tip
One or two 10-20-mL syringes; smaller syringes preferred due to ease of use

Procedure: Laparoscopic Transversus Abdominis Preperitoneal Plane Block

Prior to performing the transversus abdominis preperitoneal plane (TAPP) block, the operator confirms no allergy or other contraindication(s) to the chosen local anesthetic; if long-acting local is used, the patient should not receive any other local anesthetics for 72 hours.
- The TAPP block is typically performed prior to the principle procedure (preemptive analgesia) as long-acting local anesthetic has a long-onset time, which is overcome by the addition of bupivacaine to the dilution.
Spinal needle tip is blunted by tapping it against a malleable retractor or other flat metal surface.
The extension tubing is connected to the blunted spinal needle and to a syringe prefilled with diluted local anesthetic of choice.
After obtaining pneumoperitoneum, under laparoscopic visualization, the surgeons finger is used to identify the correct sites for infiltration at the midclavicular line in each of the four abdominal quadrants; key is to stay as lateral as the sterile field allows as the nerves bifurcate laterally.
After piercing the skin, the operator feels for two pops; the first as the needle traverses the external oblique fascia, followed by the second pop of internal oblique fascia consecutively, thereby gaining access to the TAPP.
A total of 20 mL of local anesthetic is then infiltrated into each of four quadrants; note the TAPP block works by the local spreading along the TAPP where the neurovascular bundle lies. If the spinal needle is placed
- too superficial, the operator may observe a bleb at the level of the skin, and the needle should be advanced.
- too deep, the operator will observe a preperitoneal bleb, and the needle should be withdrawn a millimeter or 2.
The remaining local anesthetic is used for port sites (5 mL each) and ostomy/extraction site fascia and skin infiltration using the 22- or 23-gauge 1- or 1.5-in needle.

EQUIPMENT LAPAROSCOPIC OR SINGLE-INCISION LAPAROSCOPIC SURGERY DIVERTING LOOP ILEOSTOMY

Technique

Traditional Method

3-0 chromic and 3-0 absorbable suture to mark proximal and distal bowel (white up, brown down, respectively)
4-0 absorbable monofilament and steri-strips to close the 5-mm port sites
Routine use of small Marlin stoma rod (removed at 48 h), typically not sutured in place
Two 3-0 chromic sutures to mature stoma, no Brooking stitches (everting sutures)
Ostomy paste and appliance

Alternative Method

Two packs of 3-0 absorbable braided pop-offs to mature stoma
All sutures are cut at end.
Highly selective use of Marlin stoma rod or red rubber catheter in cases of thick anterior abdominal wall and heightened concern for stoma retraction
4-0 absorbable monofilament and skin glue to close skin at 5-mm port sites, no dressings
Ostomy paste and appliance

Procedures: Laparoscopic or Single-Incision Laparoscopic Surgery Diverting Loop Ileostomy

Traditional Method

A quarter-sized disc of skin is grasped with a Kocher clamp and incised with a #15 blade at premarked ileostomy site (Fig. 41-2).

FIGURE 41-2 ▪ Ileostomy construction: Skin incision.
The subcutaneous fat is vertically incised with electrocautery, while right-angle Crile retractors provide exposure.
The anterior fascia of the rectus sheath is cleared of fat and divided 2-cm cranial and 2-cm caudal (Fig. 41-3), with electrocautery as Crile retractors provide exposure.

FIGURE 41-3 ▪ Ileostomy construction: Vertical fascial incision.
Once through the fascia, a large Kelly is introduced through the rectus muscle; tip on the peritoneum or posterior sheath. The Kelly is opened to split the muscle, while the Crile retractors are readjusted to retract the muscle, exposing the posterior layer (Fig. 41-4).
Two tonsils are used to elevate the posterior layer, which is divided sharply with a Metzenbaum scissor.

FIGURE 41-4 ▪ Ileostomy construction: Muscle-splitting technique.

Alternative Method

The premarked ileostomy site is circumferentially infiltrated with local anesthetic of choice.
A quarter-sized disc of skin is incised with electrocautery, and a core of fat down to the level of the fascia excised en bloc with the skin (Fig. 41-5), similar to a lumpectomy specimen.

FIGURE 41-5 ▪ Ileostomy construction: Skin incision with “lumpectomy.” A. A quarter sized disc of skin is removed. B. A wedge of subcutaneous fat is removed to the fascia.
The anterior fascia of the rectus sheath is cleared of fat, local is infiltrated into the fascia, the fascia grasped with a Kocher clamp, and a small disc of fascia excised of the underlying muscle with electrocautery (Fig. 41-6).

FIGURE 41-6 ▪ Ileostomy construction: Discoid fascial incision.
- A disc excision as opposed to a cruciate incision theoretically reduces the risk of parastomal hernia as it is resistant to the radial forces of expansion, as compared with a cruciate incision and linear forces resulting in splitting or tearing of the fascia along the lines of the cruciate incision.
The size of the fascia defect should admit the surgeons two fingers to the proximal interphalangeal joints (Fig. 41-7).

FIGURE 41-7 ▪ Ileostomy construction: Trephine sizing.

Remainder of Procedure

A finger is placed into the peritoneum and swept for adhesions.
- If adhesions, may need an alternative approach to obtaining pneumoperitoneum, such as placing the 12-mm sleeve through this site and placing various 5-mm ports and then clearing the adhesions.
If no prohibitive adhesions, then a small wound protector or SILS port is placed, and a finger again swept to ensure no bowel nor omentum is inadvertently caught in the wound protector.
A 12-mm sleeve (or SILS ports) is placed into the wound protector that is held in the wound protector and the ¼-in Penrose drain used to tie the 12-mm sleeve into the wound protector (Fig. 41-8).

Pneumoperitoneum is established, and the left lower quadrant (LLQ) 5-mm port placed under direct vision (Fig. 41-9) after using the 22-gauge needle to infiltrate local anesthetic down to the level of the peritoneum.

FIGURE 41-8 ▪ Ileostomy construction: Trans-ileostomy site laparoscopic access. A. Close-up of Penrose looped around outside of the clear circular wound protector which has the trochar sleeve through it. B. A Kelly clamp is clamped flush on the Penrose to keep tension and keep airtight for establishing pneumoperitoneum.

If blood is seen with this “finder” needle, this may represent the inferior epigastric vessels; therefore, move the planned port more lateral.

The suprapubic port is placed after the left lower port such that an atraumatic bowel grasper can assist by holding the peritoneum against the pressure of the incoming port, as the suprapubic peritoneum in this position is notoriously lax.
All four quadrants of the abdomen and the pelvis, including ovaries in women, are examined for occult pathology.
The patient is placed in steep Trendelenburg position, right side up, and the cecum is identified, the appendix inspected.
The small bowel is examined retrograde using a hand-over-hand technique in its entirety to the ligament of Treitz, looking for signs of jejunoileitis (thickened mesentery, creeping fat, strictures, fistulae).

FIGURE 41-9 ▪ Ileostomy construction: Laparoscopic port placement.
The cecum is again identified, and a small bowel site is chosen back ˜20-30 cm for the site of the ileostomy.
- Note: Enough length should exist between the ileostomy and the cecum to facilitate future loop ileostomy closure; a more distal stoma will be too close to the cecum (and may be preferred in cases where colectomy is planned), while a more proximal stoma will have higher output.
It is critical to avoid an unintentionally malrotated ileostomy, which will result in maturing the efferent as opposed to afferent limb; thus, the site of the ileostomy the bowel is marked, either with electrocautery or using a surgical marker, such that proximal can easily be distinguished from distal.
- The cautery or marker is used to mark two dots proximally (“eyes to the sky,” ie, proximal/afferent) and a line distally (“the frown is down,” ie, distal/efferent, Fig. 41-10).
- Note the traditional open method was to place a Prolene proximally and chromic or absorbable stitch distally (“blue/white to the sky, brown is down,” Fig. 41-11).
  
  FIGURE 41-10 ▪ Ileostomy construction: Orienting marks.
  
  FIGURE 41-11 ▪ Ileostomy construction: Orienting stitches.
- Note an intentionally rotated ileostomy, with the afferent limb placed inferior, will be more fully diverting relative to a standard loop ileostomy with the afferent limb superior (Fig. 41-12). This intentional clockwise rotation should be such that the limb leading into the afferent limb is inferior and medial (toward the pelvis and ultimately the ligament of Treitz) and the efferent limb is superior and lateral. This is the strong preference of the senior author of this chapter to construct more fully diverting ileostomy.
  
  FIGURE 41-12 ▪ Ileostomy construction: A fully diverting loop ileostomy.
If not a SILS case, the laparoscope is moved to the LLQ port and a bowel grasper is then placed in the 12-mm sleeve to grasp the bowel.
Pneumoperitoneum is carefully released, and the site of the ileostomy carefully brought extracorporeally through the wound protector in a nonrotated manner.
The laparoscopic bowel grasper is replaced with a long Babcock clamp, and the wound protector carefully released and pulled up and over the bowel and long Babcock.
The efferent limb serosa incised with electrocautery at the prior marked site (ie, the “frown”) to the mesenteric margins, taking care not to go full thickness with the cautery and injury the backwall of the ileum.

MATURING THE STOMA

Technique

Traditional Method

If an open case, the Kocher clamps are placed on the fascia and dermis and pulled medially to ensure a straight trephine tunnel from the skin to the fascia (Fig. 41-13).

FIGURE 41-13 ▪ Ileostomy construction: Assuring a vertical trephine.
A lap pad is placed in the surgeon’s hand.
A small tunnel is created with a Kelly at the bowel-mesentery interface of the eviscerated bowel, and a small stoma rod placed and temporarily secured with two small Babcock clamps.
Brown (chromic) and blue (absorbable braided) stitches are placed to mark distal (brown) and proximal (blue), and a Marlin rod placed and left for 48 hours or until there is not undue tension (Fig. 41-14).

FIGURE 41-14 ▪ Ileostomy construction: Marlen rod placement.
Scissors are used to open the bowel on the efferent (inferior) limb (Fig. 41-15).
Three sutures are placed, full thickness from the bowel wall (at 12, 10, and 2 o’clock positions) to the dermis and the afferent limb is sutured in three places; full thickness from bowel lumen (at 6, 4, and 8 o’clock positions) to the dermis, not including the epidermis (Fig. 41-16).

FIGURE 41-15 ▪ Ileostomy construction: Opening the efferent limb.

FIGURE 41-16 ▪ Ileostomy construction: Everting sutures.
The back of Adson forceps is used to spout the proximal bowel as the three sutures are tied sequentially.
The efferent limb is then sutured to the level of the skin.

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