Laparoscopic port setup : three 5 mm ports and a 12 mm port
Adhesiolysis and Intestinal Dissection
The extent and density of adhesions can vary significantly from case to case. It is for this reason that we believe that diagnostic laparoscopy should be performed in every patient before committing to an open operation. In some cases, minimal adhesions are found, and laparoscopic reoperative resection will be as straightforward as primary resection. In Crohn’s patients, it is thought that this may be due to their chronic immunosuppression. More typically, however, extensive laparoscopically lysis of adhesions and bowel mobilization will be needed to expose anatomic landmarks and the pathology. Even if the case is ultimately converted to open due to inability to fully expose the pathology, the size of the extraction may be reduced by having mobilized the bowel proximal and distal to the pathology laparoscopically. Surgeons should be familiar with multiple techniques for safe adhesiolysis .
In general, sharp “cold” dissection with endoshears is safer than using monopolar cautery or bipolar energy and will avoid inadvertent burn injury and delayed enterotomy. There is a clear difference between “filmy” adhesions (nonvascular), which can usually be teased apart and easily transected, and “dense” adhesions which are vascularized or inflammatory, which will not separate without sharp dissection . The two guiding principles in adhesiolysis are preventing bowel injury and maintaining hemostasis. Traction and counter-traction principles are just as important in laparoscopic adhesiolysis as in open surgery. However, the amount of counter-traction provided by an assistant is hard to estimate and control. Serosal tearing to bowel wall can occur passively by assistant traction on the bowel against a point of fixation. Overzealous grasping of friable bowel can result in partial- or full-thickness tearing. Therefore, we prefer limiting the traction applied by the assistant and use the assistant only when necessary during this phase of the operation. The other important consideration is to stay in the proper dissection plane. When dissecting off the abdominal wall, a clear plane exists on the parietal peritoneum. It tends to be avascular. When dissecting between two loops of bowel or two loops of mesentery, it is important to go slowly and stay in the avascular plane. If bleeding occurs, it is most likely due to an improper dissection plan. After extensive adhesiolysis , it is important to check for serosal tears and enterotomies prior to moving on with the resection, and this should be repeated again at the end of the procedure. If there is any question about injury, we recommend marking the area with a suture or an endoloop for closer inspection and definitive suture repair later during the case.
Complex Crohn’s Disease Resection
As with any other complex surgery , mastery of the anatomy and careful dissection techniques are required to identify anatomic landmarks during complex or reoperative right colectomy such as the right ureter, kidney, and duodenum. Laparoscopic reoperative surgery for CD follows the same steps as for primary resection. Differences include identification of the prior anastomosis and its mesentery and careful mobilization of the anastomosis from surrounding structures, which is usually complicated by fibrosis, acute or chronic inflammation, and/or fistulas. Once mobilized fully, the planned resection of the anastomosis and adjacent diseased bowel and construction of a new ileocolonic anastomosis is performed. As most patients have had the retroperitoneum exposed previously, repeat dissection and identification of landmarks is often more challenging, especially in the setting of scarring, fibrosis, abscesses, phlegmons, and fistulas. Rather than dissecting the mesentery using a medial to lateral approach during reoperative right colectomy, a lateral to medial approach may facilitate ureteral identification and avoid inadvertent injury. This is particularly useful in CD where the mesentery can be very thickened and friable and not suitable to be taken safely via a minimally invasive approach with an energy device.
Additionally, in reoperative Crohn’s disease with prior resection, the mesentery to the diseased bowel may not be readily identifiable until after full mobilization of the diseased segment and therefore best to be divided after lateral to medial mobilization.
Crohn’s Abscess, Phlegmon, and Mass
Intraperitoneal, pelvic, or retroperitoneal abscess formation remains a serious complication of Crohn’s fistulizing disease . Assuming that the collection is greater than 5 cm and there is a safe window on imaging, preoperative drainage under radiological control is standard of care. If percutaneous drainage is not possible, preoperative or simultaneous surgical aspiration may be necessary. Eventually, the diseased segment and source of the abscess requires resection.
After successful drainage of intraabdominal or retroperitoneal abscess and return to optimal health, resection of the associated segment of bowel may be attempted laparoscopically. We recommend waiting approximately 3 months to allow for the inflammatory changes to resolve and the patient to be medically and nutritionally optimized. Conversion, or hand-assisted laparoscopy with a smaller incision may be necessary in the most difficult cases, but we typically begin with a pure laparoscopic approach even in the setting of a large phlegmon . The prevailing goal in these cases is to mobilize the phlegmonous mass in order to exteriorize it through as small an incision as possible (midline or off-midline). We generally approach this using a lateral to medial approach given the thickened mesentery that tends to accompany a Crohn’s mass and the difficulty manipulating it.
Often the hepatic flexure, even if previously mobilized, is not diseased and is an optimal place to begin a lateral to medial dissection. After mobilizing the hepatic flexure, we continue the lateral to medial dissection down toward the ileocolic angle. Unfortunately, the area with greatest inflammation often tends to be adjacent to the confluence of the ureter and iliac vessels. Appropriate use of blunt dissection is paramount to a successful mobilization of the disease and avoidance of collateral damage. Our instrument of choice is the suction-irrigating device (which allows for simultaneous clearance of blood or purulence) or laparoscopic peanut which can serve as a replacement for open finger fracture dissection. A bipolar or ultrasonic device should be available to lyse scar tissue when determined safe. Eventually, the scar will need to be penetrated leaving the mesentery of the ileocolic region, and the mass can be mobilized medially. If one enters a retroperitoneal plane, one must be careful to remain superficial and anterior to the ureter. Ureteral catheters with and without the use of lighted devices or indocyanine green (ICG) can be used at the surgeon’s discretion for ureteral identification.
Ileosigmoid and ileorectal fistulae are relatively common in patients with fistulizing disease. One large case series estimated the prevalence of internal fistulizing disease at 6% for all CD patients and, of those, 19% possessed fistulas from the ileum to the sigmoid colon . In these fistulae, the inflamed terminal ileum most commonly adheres to the medial aspect of the sigmoid colon, which is usually otherwise healthy, but on occasion there is disease of both the terminal ileum and sigmoid colon. Because of this, dealing with the sigmoid side of the fistula can involve either simple division across the fistulous tract with resection of only the diseased ileocolic segment or en bloc resection. While simple ileosigmoid fistulae can often be approached laparoscopically, fistulae low in the sigmoid colon or more distal in the region of the rectouterine or rectovesical pouch may require a hand-assisted or open approach.
Difficult Crohn’s Mesentery
As discussed previously, the friable and thickened Crohn’s mesentery presents a unique challenge, as often the standard energy devices are not adequate to seal the vessels. For this reason, we recommend mobilizing the diseased bowel first to lift the mesentery off the retroperitoneum prior to mesenteric division. Once the diseased bowel is mobilized, a decision is made whether to transect the mesentery intracorporeally or extracorporeally. If the mesentery appears thin and pliable and amenable to division with an energy device, laparoscopic transection can be attempted. Additionally, the mesentery further away from the bowel wall may be thinner and more amenable to standard division with an energy device. In these situations, a high ligation and mesenteric division similar to that for oncologic resections is recommended. There are many devices well equipped to deal with intracorporeal mesenteric division. These include ultrasonic, bipolar, mechanical (staplers and clips), and monopolar electric devices. All can be utilized to divide the mesentery and control bleeding. When these fail, the surgeon needs to be ready with a backup plan which may include laparoscopic suturing or temporary pressure control and conversion to open.
If the mesentery appears to be very bulky and is deemed to be at risk for bleeding after transection with a bipolar device, then it may be safer to perform mesenteric division in an extracorporeal fashion. By mobilizing the diseased and adjacent normal bowel, at least the extraction incision will be smaller than if approached open to start. When in doubt, and if there are questions about vascular control, performing this portion of the procedure in an open fashion is safer. When ready to extract and divide mesentery, we make a periumbilical incision, place a wound protector, and exteriorize the diseased bowel. Occasionally, the Crohn’s mass is too large to fit through the small extraction site, so the skin incision may need to be enlarged. It is critical that one maintains control of the proximal portion of the mesenteric vessels during exteriorizing the bowel and mesenteric transection in order to reduce arterial bleeding and/or hematoma formation. After exteriorization, one can place a soft bowel clamp toward the root of the mesentery and use the bipolar device on the more distal portion of the vessel. Even with this technique, it is not uncommon to require multiple 2-0 Vicryl sutures in a figure-of-eight fashion or horizontal mattress fashion in order to control bleeding vessels after attempted control with an energy device or even clamp and tie technique. With the specimen already exteriorized, resection and anastomosis will follow mesenteric transection through this incision.
After the mesentery has been divided intracorporeally, one can then decide whether to make an intracorporeal or extracorporeal anastomosis. In addition to the patient’s pathology, the surgeon’s comfort and proficiency plays a role in this decision, and we will outline both approaches in the next two sections. The benefits of an intracorporeal anastomosis include but are not limited to the need for more limited mobilization of the bowel as it does not need to be exteriorized until after division. Ability to place the extraction site at any location, preferably Pfannenstiel or off midline/planned stoma site, as this is associated with decreased pain and decreased subsequent hernia formation.
Our preferred intracorporeal ileocolic anastomotic technique is as follows . Once the mesentery and specimen have been divided, the two ends of the bowel are aligned in an isoperistaltic fashion (antiperistaltic is another option), after the mesentery is visualized at its base. This is an important maneuver to ensure there is no twisting of the anastomosis. If this step is followed, it is impossible to twist the anastomosis. Stay sutures are often placed to help align the bowel and to help with manipulation during stapler placement. Once the intestine is aligned, an enterotomy is made in both the proximal and distal bowel. We prefer to do this with cutting current electrocautery, but ultrasonic devices can be used. If the intestine is dilated from obstruction, a laparoscopic “bulldog” clamp can be placed on the proximal side at least 10 cm up from the planned anastomosis to prevent spillage. Often, however, the pressure of the pneumoperitoneum is enough to prevent enteric spillage. Once the enterotomies are made, an endoscopic linear stapler is placed into each limb of the intestine and fired to create the side-to-side anastomosis. A 60 mm load is preferred but a 45 mm is acceptable. We prefer a purple load, but vascular or thicker loads may be required based on the condition of the bowel and surgeon preference (Fig. 16.4). At this point, the inside staple line is checked for bleeding. Any bleeding must be controlled now before the common enterotomy is closed. We prefer bipolar energy to control bleeding points on the metal staple line, but this can also be controlled by monopolar cautery, clips or suture ligation.
Pitfalls and Troubleshooting
Avoid previous scars. Use either optical trocars or open Hasson techniques depending on expertise of the surgeon. After subsequent trocar placement, always look back at the original trocar and the abdominal wall to make sure a through and through or occult injury has not occurred. In the unoperated abdomen, a Veress needle has also been shown to be a safe entry as well.
Use sharp dissection whenever possible. Beware of the “aggressive” assistant. Traction injuries from graspers are common in laparoscopic surgery. If there is troublesome bleeding during adhesiolysis , it is likely that the wrong surgical plane has been entered. Stop the dissection and correct the plane of dissection. After adhesiolysis, always go back and visualize the areas lysed to be sure a bowel injury has not occurred. If there is any suspicion of injury, repair is indicated. If there is any question, exteriorization of the segment is advised.
Duodenum and Right Ureter
It is critical that these two structures be clearly identified during mobilization of the right colon. The best plane for proximal transverse colon mobilization is right on the duodenum, and we advise that a sweeping-blunt technique be used when possible with minimal energy use. Any injury or potential injury to either of these structures must be immediately addressed.
This has been discussed in detail above. Bleeding can be profuse from inflamed mesentery ; therefore, suturing skills should be obtained before tackling difficult mesenteric dissection via minimally invasive techniques. Consider higher ligation as in cancer cases as the mesentery tends to be thinner in this area compared to immediately adjacent to the bowel wall. Laparoscopic or open figure of 8 or horizontal mattress sutures placed while the mesentery is compressed and controlled can get the patient and surgeon out of a difficult situation. Mechanical staplers do not work well on the thickened mesentery , and in general, they should be avoided unless the jaws will close easily around the vessels.
Keeping the anastomotic leak rate low is important. In order to avoid twisting the anastomosis, the base of the mesentery must be identified and the edge of the mesentery traced up to the cut end of the bowel. At the completion of the anastomosis, it should look correctly oriented. If there is any doubt as to that, we strongly recommend that the anastomosis be redone.
In general, the patients look well, and they are ambulating the first evening or certainly the next day. The WBC can be elevated, but it is highly unusual for that to last more than a day or two. There are some studies that suggest following CRP is a more predictive value in assessing for postoperative complications such as anastomotic leak. It is not uncommon to have a low-grade temperature for a day or two, but not more than that. While a little nausea is common, vomiting is not. The abdomen can, of course, be a little tender for the first day or two, but usually not more than that. If the patient does not adhere to these clinical parameters, it is likely that there is something wrong. We have a very low threshold to take the patient back to the OR for a diagnostic laparoscopy to make sure that the anastomosis is intact. An early CT of the abdomen in our experience almost never tells the real picture of what is happening in the abdomen. Additionally, if there is high clinical concern over the patient’s status, there are very few findings on CT that absolve the concern and prevent return to the OR. When returning to the OR, we prefer a laparoscopic approach to asses for anastomotic leak or occult bowel injury or bleeding as most can be dealt with in this manner. It is a mistake to wait until the patient is overtly ill before returning them to the OR.
Ileostomy and Conversion
Temporary ileostomies are occasionally needed. Decisions for end or loop stoma creation should be definitively made preop based on the patient’s overall condition. This is often based on patient-related factors such as nutritional status, lab values and immunosuppressive medications, and recent weight loss. Occasionally the decision to create a stoma is made based on intraoperative conditions such as finding an abscess, dilated/thickened proximal bowel, residual diseased bowel, and/or the need for double resections. Marking the patient preoperatively is mandatory to avoid the issue of improper stoma creation if the decision is made based on unplanned operative findings. We believe that the anastomosis should be perfect in appearance, or it should be revised. We do not divert to compensate for a suboptimal anastomosis.
The threshold to conversion to open or hand-assist will vary based on the surgeon’s experience and expertise with advanced skills. We strongly believe in preemptive conversion rather than reactive conversion , especially in cases where there is failure to progress due to difficulties identifying the correct anatomical planes of key landmarks. Prompt conversion will avoid injury and reduce intraabdominal spillage with associated septic complications.