Special Considerations

Patients with Crohn's ileocolitis, who have no abscess or fistula, may alternatively undergo a completely laparoscopic ileocolectomy. However, the fragility of the inflamed bowel wall, thickened mesentery, and dense adhesions may be responsible for difficulties during the procedures of mesenteric dissection, vascular isolation and ligation, and anastomosis. In laparoscopic surgery for Crohn's disease, any synchronous pathology such as strictures in skipped areas must be as reliably identifiable and treatable as it should be during laparotomy. Moreover, a small incision is ultimately necessary in order to remove the resected specimen. The size of incision is determined by the size of the specimen. Totally laparoscopic procedures with intracorporeal anastomosis are expensive, time-consuming, and provide little advantage over laparoscopic-assisted procedures.

In Crohn's disease, the mesentery is often very thick and friable, and it is the author's opinion that extracorporeal division of the mesentery is safer and more expeditious. Laparoscopic Coagulating ShearsTM (LCS) cuts and coagulates by converting electric energy into ultrasonic mechanical vibrations and allows reliable, safe, and rapid hemostasis and division, except when it is used too quickly.1 When using LCS, the position of the blade, as well as the duration of the pressure and the level of the power output, is determinant in the quality of hemostasis. Although it does not seem worthwhile to modify the direction of the blade for small vessels, coagulation of larger pedicles requires longer

Extracorporeal Anastomosis Bowel

Figure 8.2.6. Creating an extracorporeal anastomosis. A A linear stapler is used to form a side-to-side anastomosis between small bowel and the ascending colon. B The anastomosis is closed using a firing of the same stapler at a right angle to the previous staple line.

Figure 8.2.6. Creating an extracorporeal anastomosis. A A linear stapler is used to form a side-to-side anastomosis between small bowel and the ascending colon. B The anastomosis is closed using a firing of the same stapler at a right angle to the previous staple line.

application and progressive pressure with the blades in the flat position. No tension on the pedicles should be made during coagulation to avoid early division and bleeding.

To prevent the incidental enterotomy, gentle handling of the diseased bowel with endoscopic graspers is of great importance as well. The use of atraumatic instruments should be coupled with avoidance of direct grasping or handling of the diseased loop of bowel. It is also important that the dissection and mobilization should always be started in a normal area, advancing toward the diseased segment.2

During dissection of the ileocolic region, there is danger of injury to the ipsilateral ureter, which may be adherent to the mesentery because of the inflammatory process. Injury to the ureters may be lessened by the prophylactic placement of ureteric catheters. They should be placed in selected cases such as patients with a retroperitoneal phlegmon or abscess, or extensive inflammation manifested in the preoperative studies.3

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  • Thomas
    How to perform colon anastomosis with staplers?
    8 years ago

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