POSTOPERATIVE DIAGNOSIS: Crohn’s colitis with anterior abdominal wall abscess.
PROCEDURE:
1. Robot assisted ileocecectomy.
2. Robot assisted sigmoidectomy.
3. Incision and drainage of an anterior abdominal wall abscess.
4. Lysis of adhesions for 1 hour.
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 25 cc.
SPECIMENS: None.
INDICATIONS: The patient with Crohn’s colitis who has developed an anterior abdominal wall abscess and on imaging was shown to have a diseased terminal ileum and cecum with fistulous connection to the anterior abdominal wall. The patient agreed to procedure.
SUMMARY OF PROCEDURE: After the patient was consented, he was brought back to the operating room and placed in supine position where a time-out procedure was performed to correctly identify the patient and operative procedure. The patient was then induced under general anesthesia without any complications. The patient was prepped and draped in normal sterile fashion. We then entered the abdomen with a Veress needle technique in the left upper quadrant. We then placed additional ports in the left upper quadrant, right upper quadrant, midline and right lower quadrant. We began by dissecting large inflammatory mass off the anterior abdominal wall, which was connected to the terminal ileum and cecum. We noted also at this point, the sigmoid colon was densely adherent to this inflammatory mass. As we were taking this off the anterior abdominal wall, we noted fistulous connection from the anterior abdominal wall to this inflammatory mass. This was divided. After we divided the anterior abdominal wall connections and lysed adhesions for at least 1 hour, we attempted to dissect the sigmoid colon off the inflammatory mass and we noted there was also a fistulous collection between the sigmoid colon and the inflammatory mass.
After taking the sigmoid off, we then focused on dissecting out the mesentery of the sigmoid colon that had the anterior defect due to the fistulous connection. We located the inferior mesenteric artery and its branches. We were able to dissect the mesentery out, dividing all vessels and dissecting a portion of approximately 6 cm of the sigmoid colon. Using the robotic stapler, we were able to divide the proximal and distal portion of the diseased colon.
We were able to perform an intracorporeal anastomosis using 3-0 silk sutures and stay sutures, using the robotic stapler and closing the common enterotomy with a V lock suture. After this was completed, we then focused on the ileocecal mass. This was divided to a point of 4 cm proximal to the distal or diseased ileum. The healthy ileum was divided. The colon was also divided in the ascending portion of the colon again with a robotic stapler. The mesentery was taken. The ileocolic vessels were taken with the vessel sealer as well as an endo-loop. We divided the rest of the mesentery using the vessel sealer and the specimen was placed inside. We then performed intracorporeal anastomosis from the distal ileum to the ascending colon, again using the robotic stapler and 3-0 silk sutures as stay sutures and a V lock stitch to close the common enterotomy. The specimens were then taken out through the 12 mm port, which was extended, a segment of the sigmoid as well as the ileo cecal mass. These were taken off and sent off as specimen.
The abdomen was then thoroughly irrigated. The 12 mm port, which was extended for extraction of the specimen was then closed with an 0 PDS suture. The skin incisions were closed with a 4-0 Vicryl and Dermabond.
The anterior abdominal wall abscess was then opened and debrided and irrigated. This was then packed with Betadine-soaked packing and all sponge counts and instrument counts were correct x2, and Dr. was present for the entire case. There were no complications. The patient was transported to PACU in stable condition.