Laparoscopic Resection

Professor Roger Motson, Colchester

Although at first one might think operating for Crohn's disease would be an inappropriate place to start laparoscopic colorectal surgery the majority of patients with ileo-colic disease are in fact amenable to laparoscopic resection. The majority of patients are quite thin and about 2/3 will be undergoing surgery for the first time. While patients with fistulae and multi-focal disease are best avoided at first an inflammatory mass need not necessarily be as many will free up quite easily.

The technique that I use today has changed little since starting more than 10 years ago. Ports are invariably placed at the umbilicus, left iliac fossa and suprapubically with an additional fourth port in the left upper quadrant when required. The entire small bowel is inspected and 'stacked' in the left upper quadrant using gravity from a head-down, left side-down position. The telescope is in the suprapubic port, dissecting instrument in the left iliac fossa port and retracting instrument at the umbilicus. Dissection starts at the root of the ileal mesentery which is lifted upwards; this opens the plane anterior to the ureter, gonadal vessels and Toldt fascia and can be dissected up to the third part of the duodenum. Dissection is continued to the right to mobilise the caecum, right colon and hepatic flexure. Once mobilised the ileum and right colon are then delivered through a 5-6cm incision, either through the umbilicus or in a previous scar. Resection and anastomosis are performed extracorporeally, the bowel returned to the abdominal cavity, the wound closed and a final inspection performed before removal of the ports.

In 124 cases the conversion rate has been 10% consistently throughout the series. It is usually possible to deal with recurrent disease - adhesiolysis is usually required but the length of bowel to be mobilised is usually less. Additional procedures such as strictureplasty, segmental small or large bowel resection have been necessary in 8 patients. Although the majority of cases have been for terminal illeal disesase, either primary (68) or recurrent (40) isolated small bowel resections (9), stricutreplasties alome (2), colonic resection (2), subtotal colectomy and ileorectal anastomosis (3), abdomino-perineal resection (1) and reversal of Hartmann's procedure (1) have all been performed successfully.

Of particular interest are 13 patients who have undergone a second laparoscopic resection; none required conversion and the complete absence of small bowel adhesions was impressive in many. Laparoscopic resection for Crohn's is going to become increasingly 'normal'.

Motson RW, Kadirkamanathan SS, Gallegos N. Minimally invasive surgery for ileo-colic Crohn's disease. Colorectal Dis. 2002 Mar;4(2):127-131.