VM01 - Robotic Ileocolic Resection for Crohn’s Disease with Iliopsoas Fistula

Purpose/Background: A robotic approach to colorectal surgery offers similar morbidity and mortality to conventional laparoscopy. As surgeons have gained more experience, and the da Vinci Xi® has enabled multiquadrant surgery, a robotic platform has been used for increasingly complex procedures such as resections for complex Crohn's disease (CD).

Methods/Interventions: We report a case of a penetrating CD complicated by an iliopsoas abscess managed with robotic ileocolic resection. This is a 24-year-old female who was diagnosed with Crohn’s ileitis 3 years prior to presentation and was started on humira. Although initially her abdominal pain has resolved later she required switching to stelara. Her abdominal pain continued to worsen requiring an emergency room presentation where she was found to have an abdominal collection and a peri-ileocolic phlegmon. At that time she was started on intravenous antibiotics and underwent a percutaneous aspiration by interventional radiology and subsequently her symptoms have improved. After discharge from the hospital, a follow up imaging revealed a large right iliopsoas abscess and complex CD concerning multiple fistulous tracts and sinus tracts. She underwent a percutaneous drainage and was started on antibiotics and referred to our hospital for surgical interventions. She was taken to the operating room for a robotic ileocolic resection, psoas abscess drainage and end-to-side stapled anastomosis after cystoscopy and bilateral ureteric stent placement by urology. Abdomen was entered using a Hasson port at the umbilicus. Pneumoperitoneum was established. Four 8-mm robotic ports were placed in addition to an 8 mm assistant port. Chronically inflamed and adhered distal ileum was seen and the dissection began medial to lateral fashion with identification and takedown of ileocolic vascular pedicle and preservation of underlying second and third parts of duodenum. Hepatic flexure was mobilized which allowed complete medialization of right colon. The iliopsoas fistula was identified and taken down robotically. Right ureter was easily identified thanks to ureteric stent and intraluminal indocyanine green. Frank purulence was aspirated from the psoas muscle. After assurance of hemostasis, the Xi robot was undocked. A transumbilical midline incision was made and the specimen was then removed from the field. An end to side ileocolic anastomosis was done using a 29 mm EEA circular stapler. A 19 fr Blake drain was left in pelvis and abdomen was closed.

Results/Outcomes: There were no intraoperative or postoperative complications. Patient was discharged to home on postoperative day 4 after an uneventful recovery.

Conclusion/Discussion: In CD related iliopsoas abscess, surgical treatment should be considered to prevent further complications even after successful percutaneous drainage. Robotic ileocolic resection and primary anastomosis (using da Vinci XI) is safe and feasible for complex penetrating CD in experienced hands.