1. Introduction

a. Mark Patient

b. Inject Local Anesthetic

2. Surgical Approach

a. Incision

b. Dissect into Peritoneum

c. Placement of Trocars

3. Access

4. Mobilize Colon

5. Divide Distal Sigmoid Colon

6. Pull Colon Through Infraumbilical Port Site

7. Divide at Ileum and Make J-Pouch

8. Secure Ileal End of EEA Stapler

9. Regain Laparoscopic Access

10. Insert EEA Stapler

11. Anastomosis

12. Test Anastomosis

13. Reposition Omentum

14. Examine Resected Colon

15. Closure

16. Post-op Remarks

Crohn's disease is a type of inflammatory bowel disease that can chronically affect the entire gastrointestinal tract, with a propensity for the distal ileum. It causes transmural inflammation of the intestines, where it can cause abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition. It occurs in about 200 patients per 100,000 and follows a bimodal distribution pattern with peaks in the 3rd and 6th decades of life. The exact cause of Crohn's disease is unknown; however, it is believed to be influenced by immune system disorders, genetics, and environmental factors. Diagnosis is usually made by endoscopy and clinical history. Endoscopic findings show characteristic skip lesions, and a cobblestone-like appearance is seen in approximately 40% of cases, representing areas of ulceration separated by narrow areas of healthy tissue. There is no cure for Crohn's disease; the goal of treatment is to palliate symptoms, accomplished with both medical and surgical options. Medications such as antibiotics, aminosalicylates, corticosteroids, immunomodulators, and a variety of biologic medications are used to reduce inflammation and prevent recurrence. Surgery is generally reserved for patients who are unresponsive to aggressive medical therapy or those who develop complications such as intestinal obstruction due to stricture, bleeding from ulcers, abscesses, and fistulas. Segmental intestinal resection of grossly evident disease followed by primary anastomosis is the usual procedure of choice. Here, we present the case of a 59-year-old male with chronic gastrointestinal problems thought to be Crohn's colitis. Colonoscopy with biopsy of multiple areas showed dysplasia, prompting surgical resection. In this case, the entire colon was affected with rectal sparing; therefore, a total abdominal colectomy with ileorectal anastomosis was performed. Laparoscopic access was gained, and the colon was mobilized and divided at the distal sigmoid colon. The colon was pulled through the infraumbilical port site and divided at the ileum, and a J-pouch was made. Anastomosis was achieved using an end-to-end anastomosis stapler and was tested using a scope; the port sites were then closed.

Watch full-length, narrated procedure of a laparoscopic total abdominal colectomy performed by Dr. Richard Hodin at MGH on a 59-year-old male with Crohn's disease and recent findings of multifocal dysplasia on colonoscopy.

Massachusetts General Hospital