VM42 - Robotic-Assisted Extended Right Colectomy for Long-Segment Crohn’s Stricture in a Patient with a Prior Gastric Bypass

Purpose/Background: As the incidence of IBD and obesity continue to rise in the U.S., the pathophysiologic relationship of these diseases remains an active area of research. As patients with obesity experience higher rates of IBD than those of average or low BMI, and patients who have undergone bariatric weight-loss surgery are at increased risk of new-onset IBD, colorectal surgeons are likely to encounter a growing number of patients with anatomy altered by bariatric surgery.

Methods/Interventions: A 50-year-old woman with remote history of Roux-en-Y gastric bypass complicated by perforated marginal ulcer was evaluated by gastroenterology for subacute abdominal pain. Colonoscopy findings were significant for a long segment (15 cm) stricture of the transverse colon with erythematous, friable, ulcerated mucosa concerning for Crohn’s disease, but biopsy was inconclusive. Given the length, location, and need to rule out underlying malignancy, she was referred to colorectal surgery for further management and ultimately scheduled for Robotic-assisted extended right colectomy.

The patient underwent surgery without complication. After abdominal entry and placement of Robotic trocars in a curvilinear fashion across the lower abdomen, the right colon was dissected using a medial to lateral approach starting by the cecum and progressing cephalad until the duodenum was visualized. The ileocolic pedicle was isolated and ligated with a Vessel Sealer. The hepatic flexure was mobilized; as dissection progressed medially special attention was given to the roux limb mesentery. The left upper quadrant was noted to have significant adhesions, likely sequelae of the prior perforated ulcer. The splenic flexure was fully mobilized, and the transverse colon mesentery was divided after ensuring the roux limb mesentery was completely freed from any adhesions or attachments. Indocyanine green (ICG) was used to verify good perfusion at the planned transection points of the distal ileum and descending colon, which were then each divided using a 60 mm blue loaded Surefoam stapler, and the remaining mesentery was divided with the Vessel Sealer. The distal ileum was delivered under the Roux limb to maintain its antecolic position and a side-to-side isoperistaltic anastomosis was created. The colon specimen was removed and upon inspection was noted to have wall thickening and creeping fat.

Results/Outcomes: The patient had return of bowel function on post-operative day one and discharged home on post-operative day three. Final pathology demonstrated transmural inflammation of the transverse colon with ulceration and granulomas consistent with Crohn’s disease. At clinic follow-up she reported resolution of her abdominal pain and marked improvement in her bowel habits.

Conclusion/Discussion: This case was notable for the patient’s complicated surgical history and gastric bypass anatomy. The ileocolic anastomosis was intentionally positioned to preserve the antecolic Roux limb anatomy, as this orientation has been associated with a lower rate of internal hernias and small bowel obstruction. Additionally, this configuration will facilitate technically easier bypass reversal, if indicated, in the future.

Operating on colonic Crohn’s disease in a patient with prior Roux-en-Y gastric bypass is technically challenging. The robotic platform offers increased visualization, enhanced dexterity, and ability to perform intracorporeal anastomoses, which when combined with ICG assessment of perfusion, offers a safe and feasible approach.