VM29 - Robotic Ileocolic Resection with Mesenteric Excision and Intracorporeal Anastomosis for Crohn’s Disease Complicated with Enterocutaneous Fistula and Stricture

Purpose/Background: As surgeons have gained more expertise in robotic platform, and with the assistance of the da Vinci Xi®, robotic technology is being employed for progressively complicated procedures, for Crohn's disease (CD) with extended mesenteric resections. The mesentery has recently been implicated in the pathophysiology of Crohn’s disease.
Given mounting evidence implicating the mesentery in the development of CD, the robotic platform can overcome limitations of the laparoscopic approach, particularly in the facilitation of intracorporeal anastomosis creation and extended thickened mesenteric excision for complicated CD. Our video demonstrates the robotic management of complicated fistulizing Crohn's disease by ileocolic resection and intracorporeal side-to-side anastomosis.

Methods/Interventions: A 27-year-old man with a 6-year history of Crohn's disease and many admissions to hospital for medical treatment, presented with severe abdominal pain. CT demonstrated an enterocutaneous fistula with ileocolic Crohn's disease. As a result of the poor response to medical treatment and worsening of the symptoms, the patient agreed with the recommendation to proceed with surgery. Patient was placed in a Lloyd Davies position with a 15-degree Trendelenburg and a 30-degree right-side-up position. The robot was docked from the right side of the patient. A total number of five trocars are used: four 8-mm and one 5-mm assistant trocar. Terminal ileal disease with phlegmon and enterocutaneous fistulas was identified. Initially, omentum overlying phlegmonous segment dissected and taken down. Then, the peritoneum overlying the diseased segment was dissected towards to the terminal ileum to make sure adequate length of mesentery was dissected. The ileocolic vessels are identified, dissected, and clipped. Medial-to-lateral mesenteric dissection was conducted between the embryological planes and the Toldt’s fascia. The terminal ileum and colon were transected consecutively using robotic EndoWrist staplers (Intuitive Surgical, Inc.) and an intracorporeal side-to-side ileocolic anastomosis was performed. The specimen was removed through a 3-cm Pfannenstiel incision, incorporating the suprapubic port site.

Results/Outcomes: The postoperative recovery was uneventful and patient was discharged to home on postoperative dat-3.. The final pathology report was consistent with fistulizing CD.

Conclusion/Discussion: The robotic approach to ileocolic resection with intracorporeal anastomosis is both safe and feasible when performed by experienced surgeons in the context of complex Crohn's disease. The robotic platform provides several advantages over other platforms when dissecting the thickened mesentery and meticulous vascular dissection particularly for patients complicated with CD. Wristed instrumentation, stability of the operative field, and enhanced ability to control vascular pedicles permit the surgeon to readily obtain unimpeded mesenteric access and achieve a precise dissection.