Robotic-assisted strictureplasty for Crohn's disease.

A 22-year-old gentleman with a 7-year history of Crohn’s disease was conservatively managed by his physician. Subsequently, he developed abdominal discomfort and colonoscopy was performed. At colonoscopy, a stricture was identified at the ileocecal junction (ICJ) and the scope could not advance further. Stricture was serially dilated with a through-the-scope (TTS) balloon to allow successful terminal ileal intubation. A short segment of stricture was identified at the terminal ileum just proximal to the ICJ, and the more proximal portion of the ileum was normal. A biopsy was obtained which subsequently showed chronic inflammation and granulation tissue only. However, the patient’s symptoms did not improve despite dilatation and a surgical opinion was sought. Computed tomography (CT) enteroclysis was performed which ruled out other skip lesions and confirmed the colonoscopic findings of the short segment of stricture just proximal to the ICJ. Having obtained informed consent, minimally invasive surgery was planned with possible strictureplasty or ileocecal resection. During the operation, a 12-mm camera port was inserted left to the umbilicus. Two further 8-mm ports were inserted under direct vision. A formal inspection of the abdominal contents was performed specifically to examine the whole length of small bowel and right colon with laparoscopic bowel graspers. The findings from the inspection were consistent with CT enteroclysis, and there was a short diseased segment at the terminal ileum just proximal to ICJ with fat wrapping. It was decided that Heineke–Mikulicz strictureplasty would be performed rather than ileocecal resection. A robotic camera was inserted in the umbilical port, and two robotic arms were placed in ports B and C (Fig. 1). A further 10-mm port was inserted to allow passing of laparoscopic instruments and needle for intracorporeal suturing. A laparoscopic bulldog clamp applied on the proximal small bowel was used to act as a soft bowel clamp before enterotomy (see video in ESM). Two stay sutures were inserted after a longitudinal incision made at the short segment of stricture. The laparoscopic blunt dissector was used to ensure that there was a good lumen in the ileum and the ICJ. Two-layer anastomoses were performed with inner continuous and outer interrupted. At the end of the procedure, the bowel was inspected and the bulldog clamp was removed. The patient had an uneventful recovery and was discharged home on day four. Crohn’s disease mainly affects young people, and for this group of patients, a minimally invasive surgical approach would allow early return to normal activities. There are other added benefits to applying a minimally invasive approach such as reducing the incidence of adhesions, wound infection and incisional hernia [1]. The principle of Crohn’s disease treatment is preserving small bowel and strictureplasty, and this has been shown to have good outcomes in terms of complications and recurrence [2]. However, total laparoscopic strictureplasty is technical challenging even in the hands of advanced laparoscopic surgeons [1]. In view of this, a group in New York utilized a robot to perform strictureplasty in animals and found the 3-D view and articulating wrist enhanced the intracorporeal Electronic supplementary material The online version of this article (doi:10.1007/s10151-014-1260-7) contains supplementary material, which is available to authorized users.