VM36 - Natural Orifice Extraction and Intracorporeal Management of Fistulizing Crohn’s Disease

Purpose/Background: This is an instructional video submission that highlights the laparoscopic steps of a difficult Crohn's case including fistula management, use of bilateral lighted ureteric stents for ureter identification, natural orifice extraction and intracorporeal anastomoses. We are presenting the case of a previously healthy 32 year-old male who originally presented to the emergency department with abdominal pain, fatigue, weight loss and was found to have a new diagnosis of penetrating terminal ileum Crohn's disease with localized perforation and concern for enterovesicular/colovesicular fistula. He was initially managed with with IV antibiotics and a pelvic drain, which he did not tolerate. There was hesitancy to place him on biologic therapy by our gastroenterology colleagues given his localized perforation. The decision was made to manage him with a NPO state with TPN for 10 weeks. Repeat imaging at 6 months revealed a degree of inflammatory resolution however there continued to be locules of air in the bladder concerning for a fistula. Given these findings, he was taken to the operating room.

Methods/Interventions: N/A

Results/Outcomes: N/A

Conclusion/Discussion: We started the procedure by trying to encircle the area of inflammation so we could isolate out the fistulas. We encountered a enterovesicular, coloenteric and colovesicular fistulae which were all taken down. We then resected all diseased segments. Given the benign nature of the disease and smaller specimen caliber we elected to perform a natural orifice specimen extraction with an endoscopic retrieval bag. We then conducted our ileorectal and ileocolic anastomoses respectively.  A CT cystogram was conducted on POD4 with no evidence of a leak from the bladder. As such, the foley catheter was removed and the patient was safely discharged home on POD5.