Step 1: Surgical Anatomy
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Complex patients with Crohn disease should undergo a small bowel follow-through to delineate the extent of their disease and the amount of small bowel they may be left with. Upper and lower endoscopy are also helpful to evaluate other sites of disease and guide operative planning.
Step 2: Preoperative Considerations
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With advancements in the medical and surgical management of Crohn disease, resection is the most common surgical procedure. However, a small percentage of patients with extensive strictures or who are at risk of short bowel or who have short bowel syndrome may require strictureplasty. The two procedures described here are for short and long segments involved with stricture. These techniques are associated with low anastomotic leak rates and complications.
Step 3: Operative Steps
1.
Heineke-Mikulicz (Short <8 cm)
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Carefully inspect the entire intestine to develop a strategy. Measure the remaining small bowel and record the length of strictures in the medical record. If unsure about the need for strictureplasty, the 2 cm required for bowel lumen can be tested by passing a Foley through another site and inflating to 6 cc which is 2 cm.
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The bowel above and below the proposed strictureplasty site is isolated with Satinsky clamps to prevent spillage. Using the cutting cautery, the seromuscular layer is incised down to the submucosal level. The incision is made 3 cm proximal and distal to the stricture to reach healthy bowel. ( Figure 25-1 )
Figure 25-1
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An enterotomy is made over the nonstrictured bowel end, and angled forceps are used to spread the enterotomy.
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Exposed submucosa and mucosa of the anterior wall of the stricture are then divided.
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Seromuscular sutures of 3-0 polyglactin 910 are placed opposite one another at the midpoint of the defect and separated with clamps. ( Figure 25-2 )
