Totally robotic intracorporeal side-to-side isoperistaltic strictureplasty for Crohn's disease.

The development of bowel-sparing techniques (strictureplasties) for extended stricturing Crohn's disease (CD) and the increased use of minimally invasive surgery (wound sparing) represent the two most important improvements in inflammatory bowel disease surgery from the origin. Nevertheless, the minimally invasive approach for extended stricturing forms is usually avoided primarily because of difficulties in performing complex intracorporeal sutures. We describe a totally intracorporeal robotic ileocecal resection with a yet described modified side-to-side isoperistaltic strictureplasty for an extended ileocecal CD. The strictureplasty was 6 cm long including the stricture in its middle part. Adopting this approach, the preserved small bowel was about 10 cm longer. Operative time was about 4 h, with a blood loss of about 50 ml. The patients' post-operative course was uneventful, enteral nutrition started at post-operative day 2 and gradual oral food intake from day 3. She was discharged on post-operative day 6. Histology confirmed a stricturing CD, and the patient is recurrence free at 34 months' follow-up. Our report suggests that robotic-assisted intracorporeal strictureplasty is feasible and that robotics could represent an interesting instrument for allowing the intersection between minimally invasive and bowel-sparing surgery for CD.

INTRODUCTION

The development of bowel-sparing techniques for extended stricturing Crohn's disease (CD) and the increased use of minimally invasive surgery (wound sparing) represent the two most important improvements in inflammatory bowel disease (IBD) surgery during the last two decades.

Many publications support the role of minimally invasive surgery for the treatment of uncomplicated terminal ileitis as well as for complicated or recurrent CD.[12] On the other hand, strictureplasties (SXPL) represent a valid surgical approach for CD with multiple stricturing localisation or long stenosis, providing conservative management of the diseased bowel and thereby reducing the risk of short small-bowel syndrome.[3] In recent years, many SXPL techniques have been described for short as well as for medium or extended strictures, taking on a role of great relevance for the treatment of complex CD in referral institutions.[34] Nevertheless, while the presence of an extended stricturing disease is considered an indication for strictureplasty, this indication is not for a minimally invasive approach, as a meeting point between this clinical presentation of CD and minimally invasive surgery has not yet been demonstrated. We report the first case of robotic intracorporeal ileocecal resection combined to a hand-sewn side-to-side isoperistaltic strictureplasty (SSIS), analysing the technical aspects and possible perspectives of robotics in the field of IBD as a facilitating device for intracorporeal strictureplasty.

CASE REPORT

A 31-year-old female diagnosed in 2001 with multiple occlusive episodes of CD. Treated with steroids and mesalazine between 2010 and 2013, she had recurrent episodes of occlusion which led to a steroid dependence. In October, 2014, the patient underwent enteric magnetic resonance imaging which revealed five critical ileal strictures, with fibrotic aspect and moderate contrast enhancement: surgery was necessary.

We used the DaVinci® Xi robotic system positioned at the patient's right side. The patient was in supine position, mild Trendelemburg and left rotated. The trocar placement is described in Figure 1.

Figure 1

Ports placement for robotic side-to-side isoperistaltic strictureplasty. The first trocar 12 mm (optic) was introduced with open technique into the left iliac fossa (A) and the pneumoperitoneum was induced. Then, three other trocars were placed, one suprapubic 8 mm using the right arm of the robot (B), another 10 mm in the left flank for the second operator (C) and the third, 8 mm in the left hypochondrium for the left arm of the robot (D)

The right colon was fully mobilised, and the small bowel was completely evaluated, where we found five strictures for a total small bowel involvement of 50 cm starting from the ileocecal valve. The most proximal stricture was not extremely critical (thickness = 0.8 cm, length = 2 cm) and separated by the following one by 10 cm of healthy ileum. We performed a robotic ileocecal resection including the four distal strictures since the intestinal wall was too inflamed to ensure sealing of the suture at that site. We preserved the proximal stricture that had a fibrotic consistency, performing a SSIS using our previously described modified technique.[4] The mesentery of the diseased small bowel segment and of the cecum were divided employing the robotic Vessel Sealer®. The ileocecal resection was performed with a linear stapler application at both colic and ileal edges: an outer layer with separate 3/0 stitches was robotically performed on the stapled stumps. The ileal and colonic loops (respectively diseased and healthy) were carried out in a side-to-side isoperistaltic fashion with an outer layer of continuous seromuscular absorbable 3/0 suture. A longitudinal enterotomy was then performed on both sides with the electrical hook about 1 cm from the outer layer bilaterally. A running full-thickness inner absorbable 3/0 suture line was performed to complete the whole circumference of the SSIS [Figure 2a], starting from the posterior internal layer of the suture and an inverting suture to complete the internal layer. Then, the outer seromuscular suture line was also anteriorly completed [Figure 2b]. The Video 1 shows all the steps of the procedure. The SSIS was 6 cm long including the stricture in its middle part. The specimen was extracted by a small suprapubic incision. Operative time was about 4 h, with a blood loss of about 50 ml. The patient's post-operative course was uneventful, enteral nutrition started at post-operative day 2 and gradual oral food intake from day 3. She was discharged on post-operative day 6. Histology confirmed a stricturing CD; the patient's abdominal scars at 1-month follow-up are shown in Figure 3. The patient is in perfect general conditions, free from clinical recurrence, at 34 months’ follow-up.

Figure 2

(a) Intraoperative picture: A running full-thickness inner absorbable 3/0 inverting suture line is robotically performed to complete the internal layer of the whole circumference of the ileocolic side-to-side isoperistaltic strictureplasty. On the right side of the figure, a drawing clarifying the intraoperative picture. (b) Intraoperative picture: final view of the side-to-side isoperistaltic strictureplasty after the external seromuscular suture line is completed also in its anterior layer. On the right side of the figure, a drawing clarifying the intraoperative picture

Figure 3

Post-operative picture of the abdominal scars, taken 1 month after surgery

Written informed consent was obtained from the patient for publication of this case report/any accompanying images, obtaining ethical approval from the local Experts Committee of Careggi Hospital.

DISCUSSION

Although laparoscopy may appear ideal for some patients with CD (those of young age, with benign disease and at risk of iterative surgery), the use of this surgical technique has spread only in the last two decades because of technical difficulties such as inflammatory mesenterium, the presence of fistulas, pre-and intra-operative difficulties in evaluating the disease extent and intestinal wall inflammation, as well as the patient's characteristics (malnutrition and immunosuppression) which induced surgeons to prefer open surgery or limit laparoscopy to the mobilisation of the bowel.

In 2001, Milsom et al. published the first prospective study comparing the laparoscopic to the open approach in 60 patients undergoing ileocecal resection for CD. While morbidity and mortality were similar in the two groups, there was an advantage in the incidence of minor complications in the laparoscopic group.[1] A meta-analysis of 2007 confirmed the advantage of laparoscopy, demonstrating an average hospital stay of <2 days and a lower morbidity rate.[5] A further evolution of the laparoscopic approach in a recent years has been the development of single-site laparoscopic surgery (SILS), with the aim of preserving as much of the abdominal wall as possible. Results of preliminary experience have been encouraging.[6] This analysis support the role of laparoscopy in the surgical treatment of CD although some technical aspects still remain debated, particularly for which concern the choice between a totally intracorporeal or extracorporeal resection. On this regard, the preference between the two techniques is not well explored in literature. In a study on 80 patients operated on for laparoscopic intracorporeal ileocecal resection, Bergamaschi et al. demonstrated a favourable short-term outcome regarding perioperative blood loss as well as anastomotic leakage, while the overall length of skin incision at the specimen extraction site was lower than extracorporeal technique.[7] Authors describe a totally stapled technique including only patients with CD confined to the terminal ileum and cecum with or without fistula. Moreover, even if the correlation between the length of fascia opening and the rate of incisional hernia is controversial;[8] this approach seems reasonable for such a patient with an high risk of iterative surgery, as CD patients are.

A critical analysis of the published data and our experience in clinical practice indicate that bowel-sparing techniques are difficult to be combined with a totally intracorporeal approach because the technical difficulties involved in performing complex hand-sewn intracorporeal strictureplasties by laparoscopy.[12345] However, over the last 30 years, the SXPL method has further expanded and been increasingly utilised in referral institutions where it has become very relevant in particular for the treatment of extended CD. As a result, many new techniques have been developed.[3] We recently described a modified SSIS that could be recommended for those patients presenting with an extended diseased bowel in which the proximal stricture is not too much diseased, and it can be safely anastomosed distally to the healthy bowel by a side-to-side isoperistaltic running suture. The main advantage of this technique is its simplicity suggesting it might be performed by laparoscopy.[4]

The use of robotic surgery for the treatment of CD has been less explored in the literature. Only one case of Heineke-Mikulicz strictureplasty, has been performed by a robotic approach,[9] while a side-to-side strictureplasties have never been described before by a minimally invasive totally intracorporeal approach.

The characteristics of robotics could be better exploited when complex manipulation of tissues is required for this reason, we used the robotic approach to perform an ileocecal resection combined with the intracorporeal hand-sewn side-to-side strictureplasty according to our previously described technique.[4] Our report demonstrates that robotic hand-sewn intracorporeal strictureplasties are feasible in selected cases. This could be another technical solution in the heterogeneous spectrum of presentation of CD, allowing the intersection between laparoscopy with intracorporeal resection and bowel-sparing surgery for CD patients, as it may help to bypass some of the technical limitations of conventional laparoscopy. Further studies are needed to demonstrate the effective application of this technique and the cost-effectiveness of this approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.