VM55 - Robotic Ileocolic Resection for Crohn’s Disease with Enterocutaneous Fistula Takedown

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Purpose/Background: Robotic surgery has become a cornerstone of modern colorectal surgery, offering potential benefits such as reduced recovery times and fewer complications. As surgeons gain more experience on the Da Vinci Xi platform, the robotic approach has been increasingly employed in complex abdominal cases. Robotic surgery allows for enhanced dexterity and precision with the utilization of wristed instruments, high-definition three-dimensional view of the surgical field, use of simultaneous energy devices, and improved ergonomics.

Methods/Interventions: We report the case of a 32-year-old woman with history of stricturing ileocolonic Crohn’s disease managed on Humira. The patient has experienced intermittent partial small obstruction symptoms such as nausea, bloating, and cramping abdominal pain. Her imaging and colonoscopic evaluations had all revealed severe terminal ileum (TI) inflammation and stricturing. She was scheduled for an ileocolic resection; however, surgery was deferred due to pregnancy.
During pregnancy, the patient developed an infraumbilical abdominal wall infection due to a new enterocutaneous fistula (ECF). The infection was able to be controlled with multiple courses of antibiotics and drainage procedures by interventional radiology. After she gave birth, surgery was deferred for another 6 weeks to allow her to recover fully from giving birth and optimize her nutritional status.
The patient was then taken for a robotic ileocolic resection and ECF takedown. After removing the drain, incision and drainage was done of the fistulized portion on the abdominal wall. Through this incision, a small wound protector was placed and pneumoperitoneum was achieved. Lysis of adhesions was done to bring the omentum and TI off of the abdominal wall. The ileocolic pedicle was taken early, so the right robotic arm would not cause traction on it. Following the normal planes, medial to lateral dissection was completed, taking down the retroperitoneum and the duodenum from the right mesocolon. The hepatic flexure was mobilized to prevent the anastomosis from laying atop the duodenum. The lateral abdominal wall attachments were taken to completely mobilize the right colon. There was also an adhered loop of small bowel to the TI that was initially thought to be another fistula but were only adhesions. Next, the fistula was addressed, sharply lysing all dense adhesions to the abdominal wall. Only a very short segment of the TI was noted to be involved. The fistula was taken down, and the chronic abscess cavity was drained of pus. The small bowel mesentery was mobilized entirely up to the duodenum. Stents were not placed in the ureters given that the perforation occurred anteriorly to the abdominal wall rather than posteriorly to the retroperitoneum. An extracorporeal anastomosis was then performed via the lower midline incision. At the end of the case, hemostasis was ensured, and the anastomosis and mesentery were confirmed to not be twisted.

Results/Outcomes: There were no intraoperative or postoperative complications. Her postoperative recovery was uneventful, and she was discharged to home on postoperative day 5.

Conclusion/Discussion: Spontaneous Crohn’s abdominal abscess and fistula can be initially managed with percutaneous drainage and antibiotics. Surgical resection can be delayed and diverting stoma can be avoided. Robotic ileocolic resection is safe and feasible for complex fistulizing Crohn’s disease in experienced hands.