Laparoscopic Management of Pediatric Inflammatory Bowel Disease



Fig. 32.1.
Specimen following ileocecal resection for Crohn’s disease.




Technique





  1. 1.


    The patient is positioned in the lithotomy position with both arms tucked. A Foley catheter and orogastric tube are placed for decompression of the bladder and stomach.

     

  2. 2.


    Trocars are introduced into the abdomen, with 5 mm trocars placed at the umbilicus, one in the left lower quadrant along the left mid-clavicular line, and one in the right upper quadrant along the right mid-clavicular line. This allows for access to all four quadrants of the abdomen.

     

  3. 3.


    The abdomen is explored to evaluate all of the small bowel and visible portions of the colon for evidence of disease, including creeping fat and bowel inflammation.

     

  4. 4.


    The diseased portion of the terminal ileum is identified and freed from surrounding structures using electrocautery and sharp dissection, taking care to identify and preserve the right ureter. The cecum is often taken as part of the resection if the diseased portion of small bowel is within 10 cm of the ileocecal valve.

     

  5. 5.


    Once the portion of small bowel and colon that will be resected is determined, the mesentery is divided using an energy-based device such as a harmonic scalpel just below the bowel. This facilitates exteriorization of the specimen later.

     

  6. 6.


    A linear cutting stapler is used to divide the bowel.

     

  7. 7.


    One of the trocar sites, usually the periumbilical site, is then extended to allow removal of the diseased portion of bowel. A wound protector is placed prior to removal (Fig. 32.2).

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    Fig. 32.2.
    Exteriorization of the terminal ileum through a wound protector following division of the mesentery.

     

  8. 8.


    Silk stay sutures are used to approximate the anti-mesenteric borders of the two blind ends of bowel.

     

  9. 9.


    Enterotomies are created using electrocautery, and a linear cutting stapler is used to create a common channel.

     

  10. 10.


    Following inspection of the lumen for any evidence of bleeding, the common enterotomy is closed using either a linear cutting stapler or 3-0 PDS suture with a second layer of 3-0 silk sutures to imbricate the suture line.

     


Alternate Techniques






  • A single-port technique can be used, with the port in the periumbilical position.


  • The diseased segment of bowel can be exteriorized through the periumbilical incision following dissection for manual inspection and hand-sewn anastomosis if desired.


  • Multiple variations of this technique are outlined below.


Stricture


The use of laparoscopic or laparoscopic-assisted surgery in the treatment of stricture for Crohn’s disease allows for evaluation of the small bowel, with resection or exteriorization of the involved portion if stricturoplasty is to be performed. Preservation of bowel length is a significant concern with any patient with CD, and stricturoplasty can be performed using a laparoscopic-assisted approach. In our experience, we prefer a single-port approach for this operation. This approach involves externalization of the involved segment of bowel through a small incision and subsequent stricturoplasty or bowel resection depending on the length and number of strictures and the length of remaining bowel. In the evaluation of diseased segments of bowel, instruments such as ball bearings can be used to locate and determine the severity of strictures intraoperatively.


Fistula


Treatment of fistulizing Crohn’s disease is challenging with any approach. There exists a wide variety of fistulizing diseases, ranging from fistulas between loops of small bowel to enterocutaneous fistulas or entero-vesicular fistulas or entero-colonic fistulas. Additionally, there is often an associated phlegmon with fistulizing disease, which prompts preoperative drainage prior to any operative intervention. In these cases, dissection is often difficult, and a laparoscopic approach to these cases is challenging, with a low threshold to convert to an open operation depending on the degree of inflammation, the size of an associated phlegmon if present, and the degree of scarring that is present.


Abscess/Phlegmon


The presence of abscess or phlegmon without evidence of free perforation in patients with CD often indicates a contained perforation of the bowel. Often, a percutaneous drain will be placed in these collections, which will allow for resolution of the acute process and may result in the formation of a fistula tract when the drain is removed. In these cases, laparoscopy may be used for resection of the diseased segment of bowel in the future, once the acute process has resolved, if needed for recurrent abscess or fistula formation. In up to 30 % of patients, surgical intervention can be avoided following drain placement [15].


Perforation


The presence of free perforation , with the presence of free air, free fluid, and possibly peritoneal signs, does not preclude evaluation using laparoscopy. In many cases, identification of the involved segment of bowel, as well as evaluation of the remaining bowel, is possible laparoscopically if the perforation is found relatively early. Significant contamination and resultant inflammation may preclude complete laparoscopic exploration in some cases.


Postoperative


Data regarding the rates of disease recurrence of CD among pediatric patients is lacking due to the transition of pediatric patients to adult care. Data from the adult literature shows rates of disease recurrence requiring surgery were 25–35 % at 5 years and 40–70 % at 15 years [13]. With these high rates of recurrence, reducing scarring by performing laparoscopic surgery versus open may aid in easing future operations.



Ulcerative Colitis


In the pediatric population, ulcerative colitis often presents with crampy abdominal pain rather than rectal bleeding, as occurs in adults. Additionally, as many pediatric patients with CD will present with pancolitis, caution must be taken prior to determining the final diagnosis, as many patients with CD will present with pancolitis in this population. Incidence of UC is approximately 2–3 out of 100,000 children annually [16]. Treatment of the condition often begins with medical management, for which aminosalicylates and corticosteroids are first line therapy. Additionally, biologic agents, most commonly infliximab (Remicade) and adalimumab (Humira), are an option for patients that fail first line therapies and will often be given in addition to immune modulators such as azathioprine, mercaptopurine, and cyclosporine.

Surgical treatment of UC is based on a number of factors, including response to medical therapies, patient and family tolerance for cancer risk, and nutritional status with the disease. Acute indications for surgery include fulminant colitis, profuse gastrointestinal bleeding, and severe disease causing acute systemic illness. The most common approach to surgical intervention is for a two-stage approach, in which the colon and rectum are resected, a pouch is created and anastomosed to the anus, and a diverting ileostomy is created to be taken down subsequently given a period of recovery. The operative description of this technique is described below. Potential scenarios that may lead to different operative approaches will be outlined as well.


Technique





  1. 1.


    The patient is positioned in the lithotomy position with both arms tucked. A Foley catheter and orogastric tube are placed for decompression of the bladder and stomach.

     

  2. 2.


    Single-port technique can be used in which the port is inserted through a Pfannenstiel incision (Fig. 32.3). An additional 5 mm port can be added for the dissection if needed.

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    Fig. 32.3.
    Example of single-site port in place.

     

  3. 3.


    The patient is placed in the reverse Trendelenburg position.

     

  4. 4.


    The sigmoid colon is lifted anteriorly and medially, and the left ureter is identified and preserved. The inferior mesenteric artery is identified.

     

  5. 5.


    The retroperitoneum is opened at the sacral promontory, and dissection is carried out proximally to the inferior mesenteric artery, which is ligated using an energy device, stapler with a vascular load, or clips.

     

  6. 6.


    Lateral attachments are then taken starting on the left side of the colon, and the splenic flexure is mobilized as well.

     

  7. 7.
Oct 25, 2017 | Posted by in PEDIATRICS | Comments Off on Laparoscopic Management of Pediatric Inflammatory Bowel Disease
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