Endoscopic Transcolonic Specimen Removal in Laparoscopic Ileocolic Resection for Crohn's Disease: Initial Experience

Abstract

Background: Ileocolic resections for Crohn's disease can be done entirely laparoscopically, including devascularisation, transsection and reanastomosing. The only reason to perform a minilaparotomy is to remove the specimen. Aim: To assess feasibility of endoscopic transcolonic specimen removal obviating the need for minilaparotomy. Materials and Methods: In a consecutive series of patients scheduled for laparoscopic ileocolic resection, endoscopic transcolonic specimen removal was attempted. Primary outcome parameters were success rate, operating time, complication rate, length of stay and postoperative pain scores. Results: From February to September 2008, 10 patients (seven women and three men with a median age of 31) were included. A 4-trocar approach was used. The right colon was mobilized and the mesentery was devascularised close to the bowel using ultrasonic dissection to minimize specimen diameter. Large bowel and ileum were transsected using endoscopic staplers. After bowel division, the endoscopist introduced a colonoscope up to the area of bowel transsection. When it reached the cross stapled large bowel, terminal ileum and large bowel were opened to introduce a stapler. The small bowel was clamped to avoid spillage. Using an endostapler a side to side anastomosis was created. Next, the endoscope was advanced through the remaining gap in the anastomosis, grasping the specimen using an endoscopic snare. During endoscopic removal of the specimen, the laparoscopist facilitated passage of the specimen through the anastomosis for transcolonic retrieval. After this the remaining anastomotic gap was sutured laparoscopically. In two patients with a large inflammatory mass, transcolonic removal was considered not feasible. Overall success rate therefore was 80%. Median operating time was 208 minutes (range 157-327). Median length of resected bowel segment was 25.5 cm (range 16-64), median postoperative hospital stay 5 days (range 2-10). One patient developed a Douglas abscess which was drained laparoscopically. One of the patients in which transcolonic removal was considered not possible developed a sub hepatic abscess that was drained percutaneously. Pain scores decreased quickly after surgery from 3.8 at day one to 0.5 after 28 days. Conclusion: With a success rate of 80%, transcolonic removal of the specimen in ileocolic Crohn's disease is feasible in absence of an inflammatory mass. It is associated with a fast postoperative recovery. It is however questionable whether the increased complexity of the technique and time consuming logistics are justified by the potential benefit for patients when compared to conventional laparoscopic techniques.