Emergency laparoscopic ileo-colic resection and primary intracorporeal anastomosis for Crohn's acute ileitis with free perforation and faecal peritonitis: first ever reported laparoscopic treatment.

A Birindelli,C Bertarelli,S Di Saverio,S Selleri,A Siciliani,R Lombardi,G Tugnoli,D Beghelli,A Biscardi

doi:10.1186/s40064-015-1619-x

Abstract

IntroductionLaparoscopy for abdominal surgical emergencies is gaining increasing acceptance given the spreading of advanced laparoscopic skills among modern surgeons, as it may allow at the same time an accurate diagnosis and appropriate treatment of acute abdomen. The use of the laparoscopic approach also in case of diffuse peritonitis is now becoming accepted provided hemodynamic stability, despite the common belief in the past decades that such severe condition represented an indication for conversion to open surgery or an immediate contraindication to continue laparoscopy. Crohn’s Disease (CD) is a rare cause of acute abdomen and peritonitis, only a few cases of CD acute perforations are reported in the published literature; these cases have always been approached and treated by open laparotomy.Case descriptionWe report on a case of a faecal peritonitis due to an acute perforation caused by a terminal ileitis in an undiagnosed CD. The patient underwent diagnostic laparoscopy followed by a laparoscopic ileo-colic resection and primary intracorporeal anastomosis, with a successful postoperative outcome.ConclusionsComplicated CD has to be considered within the possible causes of small bowel non-traumatic perforation. Emergency laparoscopy with resection and primary intra-corporeal anastomosis can be feasible and may be a safe and effective minimally invasive alternative to open surgery even in case of faecal peritonitis, in selected stable patients and in presence of appropriate laparoscopic colorectal surgical skills and experience. To the best of our knowledge the present experience is the first ever reported case managed with a totally laparoscopic extended ileocecal resection with intracorporeal anastomosis in case of acutely perforated CD and diffuse peritonitis.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-015-1619-x) contains supplementary material, which is available to authorized users.

Highlights

Laparoscopy for abdominal surgical emergencies is gaining increasing acceptance given the spreading of advanced laparoscopic skills among modern surgeons, as it may allow at the same time an accurate diagnosis and appropriate treatment of acute abdomen
Emergency laparoscopy with resection and primary intra-corporeal anastomosis can be feasible and may be a safe and effective minimally invasive alternative to open surgery even in case of faecal peritonitis, in selected stable patients and in presence of appropriate laparoscopic colorectal surgical skills and experience
The presence of faecal peritonitis has been considered as a contraindication to laparoscopy, because of the theoretical risk of malignant hypercapnia, due to an increased absorption of carbon dioxide in the presence of severe intra-abdominal infection and inflammation of the peritoneum, and, secondly, because of the risk of toxic shock syndrome by increased passage of toxins and bacteria into the circulation favoured by the high intraperitoneal pressure

Summary

Conclusions

Operative times are often longer than open surgery, in presence of experienced operators and selected stable patients, laparoscopic management seems to be a feasible, safe and effective surgical option even in case of faecal peritonitis. Laparoscopic resection and primary intracorporeal anastomosis, maybe be considered a feasible approach to be attempted in patients with perforated CD, even in presence of faecal peritonitis and active inflammatory bowel disease, provided a careful selection of patients, with hemodynamic stability and satisfactory general and nutritional status, when appropriate emergency and colorectal laparoscopic surgical skills are available. Authors’ contributions SDS consultant surgeon performed the operation, managed the patient in the ICU and reviewed the manuscript and the video. ABir registrar was second assisting surgeon, managed the patient in ICU, performed the literature research, wrote the manuscript, took the post-operative pictures and edited the video. Author details 1 Maggiore Hospital Regional Emergency Surgery and Trauma Center–Bologna Local Health District, Bologna, Italy. 2 Maggiore Hospital Pathology Department–Bologna Local Health District, Bologna, Italy

Introduction

Discussion