VM40 - Robotic Surgery for Crohn’s Disease: One Procedure Doesn’t Fit All

Purpose/Background: Although as surgeons have gained more experience, adoption of robotic platforms has been increasing for management of Crohn's disease (CD); disease severity and complexity might require extracorporeal anastomosis and mesenteric handling as well as conversion to open surgery. We report on 3 cases of ileal CD with different disease severity to demonstrate tips and tricks of finding the best technique for robotic assisted ileocolic resection.

Methods/Interventions: The first case is a 41-year-old male with stricturing CD complicated by enteroenteric fistula. After pneumoperitoneum was achieved laparoscopic exploration was done. A medial to lateral approach was performed and the ileocolic pedicle was ligated early to prevent tension via the robotic arm. Then we directed our attention to the hepatic flexure and started mobilizing it and taking down the lateral attachments of the right colon. In patients with stricturing, short terminal ileal disease in the absence of mesenteric inflammatory mass it is feasible to use vessel sealer to handle the small bowel(SB) mesentery. After mesocolon and SB are taken down at the level of resection firefly and ICG can be used to confirm good blood flow to the resection margins prior to stapling. When feasible, an intracorporeal anastomosis is created in side-to-side fashion using sureform white load and the common channel is closed with 3-0 V-lock in 2 layers. The specimen is removed from a small pfannenstiel incision. The second case is a 20-year-old male with penetrating ileal CD with 22 cm stricturing ileal disease and right lower quadrant inflammatory mass. Presence of inflammatory mass poses an increased risk of bleeding if the meso SB is controlled with robotic vessel sealer thus we prefer to extracorporealized the meso and manage it with heavy chromic sutures and clamps . In these cases after ligating the ileocolic pedicle, we start circling the enemy by starting with medial to lateral dissection and mobilizing the flexure and leaving the SB meso handling last. Blunt dissection to mobilize the terminal ileum should be used to avoid injuries due to surrounding inflammation. In these cases we prefer to use the periumbilical incision to exteriorize the bowel and create a stapled end-to-side stapled anastomosis. Using ureteric stents and intraluminal indocyanine green can help demonstrate the right ureter throughout the case. The third case is a 65-year-old female with complex penetrating CD with multiple ileoileal and ileocolic fistulas. She also has prior hx of bowel resection. In these very challenging cases lysis of adhesions can be carried laparoscopically to improve exposure and safe docking. When tissues are friable and meso handling easily causes mesenteric hematomas, conversion to open earlier rather than later should be considered. In these cases handsewn anastomosis might be feasible if the bowel is very thick. We prefer a single layer end-to-end handsewn anastomosis with 2-0 or 3-0 vicryl and utilize Turnbull sutures to create the posterior wall. In patients with multiple anastomosis or enterotomies proximal diversion with loop ileostomy should be considered. Most of the patients presenting with this severe inflammatory disease suffer from chronic anemia and malnutrition.

Results/Outcomes: All 3 patients tolerated the surgery well and discharged home without perioperative morbidity.

Conclusion/Discussion: Robotic surgery for CD presents unique surgical challenges. In addition to history and preoperative imaging intraoperative findings should be utilized for surgical decision making.