Ileocecal Resection Technique

Updated: Feb 08, 2017
  • Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Open Resection

The patient is placed in the supine position with arms abducted and supported on arm boards. Antithromboembolism stockings are applied. The surgeon may elect to give oral alvimopam to shorten postoperative ileus. The patient will also be given preoperative enoxaparin or heparin for prophylaxis against venous thromboembolism.

General anesthesia is induced, muscle relaxation is achieved, and the endotracheal tube is placed. Prophylactic antibiotics are administered within 1 hour of incision to cover colonic and skin flora (eg, piperacillin-tazobactam, ertapenem, or a third-generation cephalosporin and metronidazole.) A Foley catheter is placed to drain the bladder and monitor the quantity and color of urine. An orogastric tube is placed to temporarily decompress the stomach and is removed before extubation.

The abdomen is shaved, widely prepared with an iodine- or alcohol-based formulation, and draped in the usual fashion. The electrocautery, vessel sealer/ultrasonic dissector, and suction tubing are secured to the drapes. The operating surgeon stands at the patient’s left, with the assistant on the right.

A lower midline laparotomy is made from around the epigastrium to the lower abdomen. The colon, liver, and small bowel are inspected and palpated. In Crohn disease patients, small-bowel length should be measured; these patients are susceptible to short-bowel syndrome. Next, a self-retaining retractor (eg, Bookwalter) or a wound protector is placed to allow proper exposure.

The cecum with its characteristic taeniae is located in the right lower quadrant. Using the left hand, the surgeon can lift the cecum and terminal ileum medially and up off the pelvis and place tension on the white line of Toldt (the avascular plane of loose connective tissue that is formed from the coalescence of the right colon’s posterior serosa and the parietal peritoneum of the abdominal sidewall).

This line is taken down with electrocautery while tension is maintained. The plane is developed up to the hepatic flexure, and the right colon is mobilized bluntly away from the duodenum, located at the base of the colonic mesentery.

At this point, margins of resection are identified. Note that intestinal sparing is a key in Crohn disease patients, and adequate margins are not necessary. Windows in the mesentery are made up to the bowel wall by means of both blunt dissection and division with electrocautery. A gastrointestinal anastomosis (GIA) cutting stapler is used to divide both ends of the bowel transversely, and attention is then directed toward the remaining mesentery.

The mesentery can be divided with traditional clamp-and-tie technique or with a vessel sealer device. The thickened mesentery of Crohn disease patients may have to be ligated with an overlapping clamp technique. Once this is done, the specimen is handed off, and attention is directed toward creation of the anastomosis.

The remaining ends of the small and large bowel are brought into proximity. Either a stapled or a handsewn technique may be used to create the anastomosis. Sewing the bowel may allow more versatility in making up for a size discrepancy. The use of a Cheatle slit in the antimesenteric border of the ileum may be necessary to spatulate and widen it so that it matches the size of the large bowel. The mesentery may then be closed with continuous 3-0 absorbable suture to help prevent an internal hernia.

At this point, the anastomosis is palpated for adequate diameter, and the peritoneum can be irrigated with warm saline. The fascia is closed in the usual fashion. Because there usually is no gross spillage of stool, the skin can be approximated with several surgical staples.

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Laparoscopic Resection

Laparoscopic ileocecal resection can be performed for the same indications that apply to open resection (see Indications), with some exceptions. Obviously, the surgeon must be comfortable and proficient with laparoscopic surgical technique, and there must be no contraindications to performing a laparoscopic procedure.

Preoperative preparation is as previously described for open resection, with some modifications for laparoscopy. The patient’s arms should be tucked to the sides. A modified lithotomy position, with hips and knees flexed slightly, may facilitate intraoperative colonoscopy (if indicated). Pressure points should be noted and appropriately addressed before positioning is complete.

The patient should be well secured to the operating room table to allow safe rotation and tilting of the table. This will allow for proper visualization during the dissection. Video monitors should be placed on either side of the patient so that the entire surgical team has an unobstructed view.

Pneumoperitoneum is established by means of the surgeon’s preferred method (eg, open Hasson or Veress needle). Various layouts for port placement exist. The goal is to triangulate toward the cecum so as to facilitate the use of the safest and most efficient laparoscopic technique.

The camera port is placed first at the umbilicus. A 5-mm working port is placed in the left lower quadrant. Any adhesions present are lysed in a stepwise manner to allow safe placement of the remaining ports. Usually, a diamond pattern works best, with ports at the umbilicus, left lower quadrant, suprapubic area, and right lower quadrant. The surgeon’s preference and experience will dictate any deviation from this placement scheme. The surgeon stands on the patient’s left along with the camera operator; an assistant can stand on the patient’s right.

The abdominal organs are examined for any unexpected pathology that might change the planned procedure. The dissection is then carried out in a fashion similar to that described above. Trendelenburg and left-side-down positioning of the table will help keep the small bowel from obstructing the surgeon’s view.

For dividing the mesentery and vessels, including the ileocolic vessels, several options are available to the surgeon, including an endoscopic stapler, surgical clips, an ultrasonic dissector, and an electrothermal vessel-sealing device. The bowel itself is divided with an endoscopic stapler.

An endoscopic specimen retrieval bag is used to hold the specimen and store it above the liver until it is time for removal. A minilaparotomy is created as an extension of either the right lower quadrant port site or the umbilical port site. This allows removal of the specimen as well as creation of the anastomosis by delivering the bowel through the laparotomy. The anastomosis is carried out in the preferred fashion, the bowel is returned to the abdomen, and the incision is closed.

Single-port approaches have also been described, and the evidence to date suggests that they are both safe and feasible. [10, 11]

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Postoperative Care

Postoperatively, the patient is extubated and moved to the recovery area before transfer to the surgical floor. He or she is kept on NPO (nil per os) status except for oral medications for postoperative day 0. Patient-controlled analgesia (PCA) is a common choice for postoperative pain control. Maintenance intravenous fluids are continued until the patient has adequate oral intake, and a clear liquid diet is started on postoperative day 1.

Perioperative antibiotics are continued for 24 hours, and the Foley catheter is removed on the morning of postoperative day 1. Chemoprophylaxis for venous thromboembolism (eg, heparin or enoxaparin) is continued until discharge, and alvimopam (if started preoperatively) is continued until the first bowel movement. The diet is advanced when there is return of bowel function. The patient is encouraged to ambulate as early as the night of surgery and perform incentive spirometry to help prevent pulmonary complications.

Daily surveillance laboratory tests, including a complete blood count and basic metabolic panel, are obtained until the values have normalized and the patient has tolerated a diet. The patient is medically fit for discharge only after he or she has passed the first bowel movement, has tolerated at least a full liquid diet, has adequate pain control with oral medication, and has ambulated.

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Complications

Early complications of ileocecal resection include the following:

  • Excessive bleeding
  • Wound infection, including superficial and deep
  • Deep vein thrombosis and/or pulmonary embolism
  • Prolonged ileus
  • Urinary tract infection
  • Pulmonary complications (ex, pneumonia)
  • Cardiac complications (ex, myocardial infarction)
  • Wound dehiscence
  • Anastomotic leak (signs of which may be tachycardia, fever, leukocytosis, ileus, sepsis, or feculent material from the incision); in a study of Crohn patients undergoing ileocecal or ileocolic resection, steroid usage and presence of abscess preoperatively were independent risk factors for anastomotic complication at a rate of 14% (40% when both factors were present)

Late complications of ileocecal resection include the following:

  • Anastomotic stricture
  • Bowel obstruction secondary to adhesions
  • Fistula
  • Incisional hernia
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