VM93 - Robotic Ileocecal Resection with Intracorporeal Anastomosis in Crohn's Disease: Dealing with the Difficult Mesentery

Purpose/Background: Despite recent advances in medical therapy for patients with Crohn’s disease (CD), around 50% will require surgery during their lifetime, being ileocecal resection the most common surgical procedure performed in these patients (1).
Mesenteric adipose tissue hypertrophy, or fat wrapping, has been recognized on surgical specimens as a characteristic feature of CD. Mesenteric fat tissue has also been recognized as an endocrine tissue regulating metabolic processes and inflammation (2).
Laparoscopic approach in CD is often challenging because of chronic inflammation, fistulas, abscess, adhesions, and obesity. Consequently, it is associated with high rates (up to 40%) of operative conversion (3).
We present two cases of patients with CD that underwent robotic ileocecal resection with intracorporeal anastomosis (ICA). In the second case, a modified technique to take down the mesentery was employed.

Methods/Interventions: The first case is a 50-year-old male with previous medical history (PMH) of ileocolic CD refractory to medical therapy, obesity, and IBD-associated arthritis. The patient complained of abdominal pain and bloody stools. A CT scan showed signs of Crohn’s ileitis complicated with strictures. Colonoscopy reported Crohn’s ileitis. The patient underwent robotic ileocecal resection with ICA. Throughout the mesenteric dissection, the mesentery was found thickened and friable, and the vessel sealer was not capable of appropriately sealing the vessels causing intraoperative bleeding from the mesentery that was controlled with silk stitches.
The second case is a 70-year-old male with PMH of CD refractory to medical therapy, rheumatoid arthritis, and hypertension. The patient complained of severe diarrhea, fatigue, and nausea. Colonoscopy was performed and ileocecal valve stenosis was found. CT enterography showed multiple segments of mural thickening and inflammation in the terminal ileum. Elective surgery was decided. The patient underwent robotic ileocecal resection with ICA, to address the difficult mesentery a modified technique was employed. The bipolar forceps was used first for slow controlled coagulation and mesenteric thinning, then the vessel sealer was used for a controlled ligation of the vessels.

Results/Outcomes: The first patient developed a postoperative ileus on postoperative day (POD) 2, and nasogastric tube (NGT) was placed. The patient regained bowel function on POD 5, NGT was removed and was discharged home on POD 8. The second patient postoperative course was uneventful, regained bowel function on POD1, was discharged home on POD2.

Conclusion/Discussion: Crohn’s disease is a complex pathology involving chronic inflammation of the mesentery.
Tissue fracturing during mesenteric dissection may cause vessel avulsion and retraction preventing adequate hemostatic control.
This modified technique to take down the mesentery allows slow controlled coagulation, removal of mesenteric fat and controlled ligation with the vessel sealer.