Step 2: Preoperative Considerations
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The most common laparoscopic resection for Crohn disease is unquestionably ileocecal resection. The conduct and intraoperative steps vary depending on presentation and intraoperative findings. The medial to lateral approach described below is typically used with two notable exceptions:
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Thickened mesentery. If the mesentery is very bulky and difficult to handle laparoscopically, bleeding can be profuse when attempting to divide the ileocolic pedicle. In these cases the entire mobilization is performed, but the vascular pedicle is safely taken extracorporeally.
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Mesenteric phlegmon/abscess. In the setting where the mesentery is occupied by a large abscess or phlegmon a lateral to medial approach is appropriate.
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Step 3: Operative Steps
1.
Routine Ileocecal Resection
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Patient positioning: All patients are positioned with yellowfin stirrups with the legs parallel to the bed and the arms tucked. ( Figure 26-1AB )
Figure 26-1
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The primary monitor is placed on the right side of the patient. ( Figure 26-2 )
Figure 26-2
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An umbilical port is placed with an open Hasson technique, and a 10-mm, 30-degree camera is inserted.
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Additional ports: A 5-mm port is inserted 2 fingerbreadths medial to and 3 fingerbreadths superior to the right anterior superior iliac spine. Another 5-mm port is inserted in the left upper quadrant. Abdominal exploration is performed, and the small intestine is run from the ligament of Treitz to the cecum, noting any strictures or fistulas. ( Figure 26-3 )
