Ileostomy site approach for adhesiolysis and laparoscopic cholecystectomy in a hostile abdomen: A novel technique.

INTRODUCTION: : Gallstones are an etiological factor in 23%-54% of patients with acute pancreatitis. A small proportion of these patients will also have intestinal complications requiring necrosectomy with diverting loop ileostomy. Later, these patients require cholecystectomy and ileostomy reversal. Laparoscopic cholecystectomy is fraught with difficulty in these patients due to dense intra-abdominal adhesions, and many surgeons resort to an open approach. We describe a technique which takes advantage of the ileostomy site for initial access. MATERIALS AND SURGICAL TECHNIQUE: Ileostomy reversal is done and a SILS™ (Covidien, Mansfield, Massachusetts, USA) port is inserted under direct vision, through the ileostomy site. Adhesiolysis is done through the SILS™ port. Additional ports are inserted and standard steps are followed for cholecystectomy.
CONCLUSION: The use of ileostomy incision as the first port facilitates adhesiolysis and subsequent port placement in the hostile abdomen encountered in these patients. We describe a novel technique of ileostomy reversal and laparoscopic cholecystectomy using SILS™ port.

INTRODUCTION

Gallstones are the most common cause of acute pancreatitis in India and second most common cause worldwide.[12] Standard management for those requiring intervention includes step-up approach with some of them requiring necrosectomy. A small proportion of these patients will also require diverting loop ileostomy due to associated intestinal complications.[34] When the patient has recovered from acute illness, cholecystectomy and ileostomy reversal is done. Performing cholecystectomy laparoscopically is difficult in these patients mainly due to a hostile abdomen from dense adhesions and an inability to achieve adequate pneumoperitoneum safely. Surgeons in general resort to an open approach which requires two separate incisions. We describe here a technical modification which allows safe, controlled initial adhesiolysis under vision, through the ileostomy site, which is then followed by a standard laparoscopic cholecystectomy.

MATERIALS AND SURGICAL TECHNIQUE

Ileostomy closure

Standard steps are followed for ileostomy closure. Once anastomosed, the bowel is reposited in the abdomen, leaving an adequate round defect which allows insertion of a SILS™ Port (Covidien, Mansfield, Massachusetts, USA) under vision. Pneumoperitoneum is created and pressure adjusted at 11–12 mmHg. A 12 mm port is placed, and laparoscope is inserted. Using two 5 mm instruments, omentum and bowel are dissected off the anterior abdominal wall [Figure 1].

Figure 1

SILS™ port with one 10 mm and two 5 mm ports inserted for camera and instruments respectively for adhesiolysis

Laparoscopic cholecystectomy

Once adequate space is created two additional ports, 5 mm and 10 mm are placed in the subcostal region and epigastrium, respectively [Figure 2]. A 5 mm instrument is placed through one of the ports of SILS™ port and is used for upward and lateral traction on the gall bladder (GB) fundus. Standard steps for laparoscopic cholecystectomy are then followed. If the critical view of safety is not achieved we resort to subtotal cholecystectomy. The specimen is removed from the ileostomy site. The ileostomy incision is closed with interrupted sutures (polydioxanone number 1).

Figure 2

Portplacement for laparoscopic cholecystectomy

CASE REPORT

Case 1

A 38-year-old lady developed acute severe gallstone pancreatitis (computed tomography severity index [CTSI]-10). She had undergone lower segment cesarean section and laparotomy for adhesive bowel obstruction 8 years back. Further during the current illness, she developed pancreatic and peripancreatic necrosis, septic shock, acute lung injury requiring mechanical ventilation and intermittent subacute intestinal obstruction (SAIO). She underwent percutaneous drainage of the necrotic collection. She developed duodenal fistula into the residual necrotic cavity. The organ failures gradually recovered, but sepsis and SAIO persisted necessitating a laparotomy on day 53. The small bowel was dilated with dense interloop adhesions. Enterotomies and serosal injuries occurred during adhesiolysis. Primary repair with loop ileostomy was done along with necrosectomy. Her post-operative course was complicated by multiorgan failure from which she gradually recovered. She also had wound dehiscence, which healed by secondary intention. At 104 days following first surgery, ileostomy closure and cholecystectomy were done as described. The post-operative course was uneventful and histopathology revealed xanthogranulomatous cholecystitis.

Case 2

A 45-year-old man, a chronic smoker with moderately severe acute gallstone pancreatitis (CTSI-10), developed a walled-off pancreatic necrosis 2 months later which was communicating with descending colon and also had a concurrent gallbladder perforation with multiseptated abscess in segment-V of the liver. He underwent necrosectomy and diverting ileostomy. He had a stormy post-operative course and needed mechanical ventilation, vasopressors and prolonged antibiotics. He also developed a duodenal fistula and an abdominal wound dehiscence. He underwent ileostomy closure and laparoscopic cholecystectomy 205 days after the initial surgery. Ultrasound abdomen showed cholelithiasis with normal common bile duct (CBD) and liver function test was normal. He had an acutely inflamed and thick-walled gallbladder with perforation in the fundus which contained pus. The Calot's triangle was frozen. A subtotal cholecystectomy was done. Histopathology showed xanthogranulomatous cholecystitis. His post-operative course was complicated by bile leak. Magnetic resonance cholangiopancreatography showed choledocholithiasis. The fistula healed following endoscopic retrograde cholangiopancreatography and CBD stenting.

DISCUSSION

We have described an alternative surgical technique in which the ileostomy closure site is used as an initial entry (with the assistance of SILS™ port) for the initial dissection.

The merits of the technique are as follows: (1) An already present incision is used as entry port. (2) It reduces the risk of injury during first port insertion, especially in cases of intraabdominal adhesions. (3) Adhesiolysis can be done under vision and rest of the ports can be inserted safely.

The technique is particularly useful in the hostile abdomen from previous inflammatory and surgical insults. Patients who had wound dehiscence and healed by secondary intention are expected to have dense adhesion in the midline, where a safe entry is unlikely. We do not advocate completing the cholecystectomy through SILS™ port as the port is positioned much to the right of the midline and cholecystectomies are difficult following pancreatitis and necrosectomy.

Kulkarni et al. have also described a combined procedure of ileostomy closure with cholecystectomy in two patients with post-colorectal surgery gallstone pancreatitis.[5] They have used a 12-mm balloon-tipped port after partially closing the fascial defect which was used as camera port. In addition to the 12 mm camera port, three additional ports were placed for a standard four-port laparoscopic cholecystectomy. The major drawback of this technique is in patients with dense intra-abdomimal adhesions, where adhesiolysis is necessary even before placing additional ports. The additional ports of the SILS™ port can be used for this purpose and one of them can be used for retracting the GB fundus.

CONCLUSION

We have described a simple and reproducible technique for ileostomy reversal and laparoscopic cholecystectomy. This technique is useful in patients who are likely to have dense intra-abdominal adhesions, such as patients following necrosectomy and those whose wounds healed by secondary intention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.