eP100 - A Superior Approach to Robotic Ileocecectomy in an Obstructed Patient with Crohn’s Disease

Sunday, June 2, 2024

8:00 AM – 8:05 AM ET, USA

Location: Baltimore Convention Center, Room 318-320

ePoster Presenter(s)

Gustavo R. Rodriguez, MD (he/him/his)

Resident Physician
George Washington University Hospital
Washington, DC, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Author(s)

Carina L. Felix, MD

General Surgery Resident
George Washington University Hospital
George Washington University Hospital
Ft Washington, MD, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.
AI

Aisha Inuwa, MD

General Surgery Resident
George Washington University Hospital
Washington, District of Columbia, United States

Disclosure information not submitted.

Senior Author(s)

MN

Matthew Ng, MD, FACS

Assistant Professor of Surgery
George Washington University Hospital
Washington, District of Columbia, United States

Disclosure information not submitted.

Purpose/Background: Novel pharmaceuticals have allowed for a decrease in rates of surgical intervention in the management of Crohn’s Disease (CD). Even so, most patients require at least one surgical intervention during the course of their disease; up to 47% of patients require surgery within 10 years of diagnosis.1,2 The terminal ileum (TI) is commonly affected in CD, often developing fistulae and strictures that warrant surgical intervention. 3 Studies have shown that minimally invasive techniques have lower rates of anastomotic leaks, need for reoperation, and wound site infections when compared to open surgery.4 Within those techniques, surgical approach should always be tailored to the individual patient. We present a case of a 30 y/o female with a small bowel obstruction complicated by interloop abscesses with evidence of fibrostenotic and fistulizing disease secondary to a CD flare requiring a superior approach for robotic ileocecectomy and small bowel resection.Methods/Interventions: A 30 year old female with CD on immunosuppressive therapy presented with 10 days of right lower quadrant (RLQ) pain, intermittent vomiting, and poor PO intake. An initial abdominopelvic CT showed thickening of the cecum, TI, and appendiceal base with surrounding inflammatory changes and an associated 3.7cm abscess. She was hemodynamically stable and without peritonitis, so medical management with antibiotic therapy was initiated. After several days of persistent pain with worsening obstructive symptoms, a repeat CT scan showed continued progression of the disease with multiple interloop abscesses with new interloop fistulous tracts and a TI stricture. After multidisciplinary discussions, she underwent a robotic ileocecectomy with ileocolonic anastomosis and small bowel resection. This is usually performed with trocars placed linearly from the left upper quadrant to the suprapubic region allowing for dissection and mobilization to be done in a medial to lateral fashion.5 Given the extent of her disease, the small bowel obstruction, and multiple abscesses extending anteriorly to the abdominal wall musculature, a superior approach was adopted with trocar placement extending transversely from the right upper quadrant to the left flank. This allowed for reduced risk of bowel injury upon entry to the abdomen by avoiding the inflamed, dilated small bowel and multiple abscesses while still providing adequate exposure for the procedure. In this manner, the dissection and mobilization is done in a lateral to medial and inferior to superior fashion.Results/Outcomes: The patient tolerated the procedure well and, after conservative management of a postoperative ileus and completion of antibiotic course, she was discharged home tolerating PO intake.Conclusion/

Discussion: Though medical therapy is the cornerstone of management of CD, almost all patients will undergo at least one surgical intervention to treat a complication. About 19-38% of patients have stricturing or penetrating complications at time of diagnosis, and up to 61-88% will develop these complications within 20 years. 6 Although it has been demonstrated that minimally invasive techniques have better outcomes than open surgery, the specific surgical approach must be tailored to each patient. This case demonstrates how a superior approach to a robotic ileocecectomy optimizes trocar placement to reduce the risk of iatrogenic bowel injury in a patient with extensive disease and multiple abscesses, while still allowing for appropriate exposure to efficiently perform the procedure without complications."Port Placement for a Robotic Ileocecectomy

Common port placement for a robotic ileocecectomy extends from the left upper quadrant to the suprapubic region (left). The port placement for a superior approach, as was performed in this case, extends transversely across the upper abdomen from the right upper quadrant to the left flank (right).
Abdominopelvic CT Scan

A representative image of the patient's preoperative abdominopelvic CT scan demonstrating extensive soft tissue inflammation with thickening of the cecum (red arrow), terminal ileum (blue arrow), and a loop of jejunum (green arrow). Also visible is one of multiple interloop abscesses extending to the anterior abdominal wall (yellow arrow).
Intra-operative View of Peritoneal Cavity and Adhesions

This cephalocaudal view of the peritoneal cavity demonstrates the extensive omental and small bowel adhesions to the anterior abdominal wall (top of image) in the region of where traditional port placement would be."