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Case A 44-year-old-male patient with no surgical record. He had a history of Crohn's disease, which was diagnosed 24 years before. He received steroids during one year and remained asymptomatic afterwards. He presented with diarrhea and abdominal pain. Further investigation was performed by means of a colonoscopy that revealed a stenosis at the ascending colon without identifying the ileocecal valve. The MRI was compatible with intestinal nonrotation as the small bowel was to the right of the colon. There was a 3-cm inflammatory pattern at the terminal ileum and ileocolic stenosis. This stenosis was not susceptible of endoscopic dilation.
Surgical treatment was performed by MIS. The patient was placed in the supine position with opened legs to allow better positioning of the surgeons if required. A total of 4 ports were used: a 12mm port at the umbilicus for 3D scope with a flexible tip; another 12mm port in the supra pubic position; and two 5mm ports located at the epigastrium and the left iliac fossa. The leading surgeon stood at the right of the patient with one assistant on each side. The first maneuver was to create a window at the mesentery of the terminal ileum. We use the Ligasure™ to dissect and improve bleeding control. The assistant surgeon grabs the ileum to improve exposure. We make sure that the mesentery is fully dissected and introduce a mechanical suture for section of the small bowel. Articulated mechanical cartridges are particularly useful in these cases as they increase the range of maneuver to accomplish organ sectioning. Now the terminal ileum is grabbed pulling the cecum towards the head of the patient, this exposes the retroperitoneal surface of the colon and the avascular plane that should be followed. The assistant surgeon maintains this traction. The hook is used to individualize the ascending colon from the left flank. The non dominant hand of the leading surgeon improves exposure. At this stage special care should be taken to avoid ureteral injuries. Now the assistant surgeon pulls the descending colon while the leading surgeon pulls in the opposite direction from the cecum. The attachments between these colonic segments become evident and the Ligasure™ is used to release them. This device can also be used for blunt dissection. A tunnel was created at the posterior surface of the colon. Passing the device behind the colon like this makes it possible to identify a landmark on the lateral surface to create a window that connects both dissections. Passing the laparoscopic Debakeys reveals the correct path. A purple EndoGiaTM Tri-Staple™ with a curved tip was guided through this path to accomplish the section of the colon. Once again the articulated featured played a key role to accomplish this phase of the surgery. After sectioning the proximal and distal margin the surgeon detaches the retroperitoneal surface of the specimen. The exposure of the colon was accomplished by pulling it towards the lateral and the Ligasure™ was used to take down these adhesions, the mesentery of the terminal ileum is divided. We seal twice with the ligasure before cutting in patients with IBD. Step by step the mesentery is divided completing the detachment of the specimen that was extracted through a small Pfannenstiel incision. As this is a case of intestinal nonrotation, the bowel transit was restored with the ileum placed to the lateral and the colon to medial. A knot was made to maintain traction and orientation of the colon and the ileum during the intracorporeal anastomosis, the assistant surgeon will be in charge of maintaining traction. The hook is used to create a colotomy and a enterotomy. A purple EndoGiaTM Tri-Staple™ of 60mm was used to built the anastomosis. First we introduce the tip of the mechanical suture and then we pull from the small bowel or the colon. The defect was closed with a Vicryl running suture. These steps are similar to those performed to create the foot of a roux limb. Finally, we also tightened the knot made to provide traction and direction. It serves to release tension in the anastomosis.
The surgery took 120 minutes and was uneventful. No drainage was left. The patient started oral intake on the first postoperative day and left hospital on the fourth day after surgery. Pathological examination was compatible with Crohn´s Disease in a fibrotic stage which caused stenosis and mild inflammatory activity. No malignancy was found Six months after surgery the patient remains asymptomatic.
