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INDICATIONS

Although surgical therapy cannot cure Crohn’s disease, it can palliate the complications of regional enteritis, including stricture, bleeding, fistula, abscess, or perforation. Bowel preservation is the guiding principle for surgical therapy of Crohn’s disease. Only the grossly affected portion of the bowel should be resected. This minimizes the risk of a “short gut” after multiple resections, and reduces the risk of malnutrition. Therefore, if one or more short noninflamed strictures were to cause obstruction, strictureplasty avoids any loss of bowel. This technique can only be done for fibrotic strictures, as this reconstruction will not heal in the setting of acute inflammation. Further, because of a risk of cancer, the stricture should be biopsied prior to any such reconstruction.

PREOPERATIVE EVALUATION

When possible the extent of disease should be defined preoperatively with colonoscopy and/or imaging. Imaging techniques include small bowel follow-through, conventional computed tomography (CT), or CT enterography.

Prior to either ileocecectomy or strictureplasty, improvement of nutrition, minimization of steroids, and treatment of anemia are essential. Patients who are severely malnourished, anemic, and on a high dose of steroids and other immunosuppressive agents may not be a candidate for a primary ileocecal anastomosis. Patients on infliximab (Remicade) or other monoclonal antibodies should have elective surgery delayed until 8 weeks have passed following the last dose of medication. Bowel preparation is generally not required. Preoperative steroid doses should be tapered to as low as possible. Ideally, patients should be anabolic prior to elective operation.

Thromboembolism prophylaxis, either pharmacologic or mechanical, is appropriate, particularly in the setting of inflammatory ileocecal disease. Prophylactic antibiotics that cover intestinal flora are given prior to skin incision. After induction of general anesthesia, an orogastric tube and urinary catheter are placed.

POSITIONING

A beanbag can be placed under the patient to facilitate positioning. With true ileal or ileocecal disease, simple supine positioning is adequate. If more of the ascending colon is involved and there is a possibility of having to mobilize the hepatic flexure, the patient should be placed into a low lithotomy position with Allen stirrups. Each ankle, knee, and opposite shoulder should be aligned. No pressure should be placed on the peroneal nerves or calves. The angle between the thigh and the plane of the bed should not be more than 10 degrees. Any greater hip flexion will limit the range of motion for instrumentation. Excessive hip extension may lead to an anterior dislocation of the hip.

Each elbow (ulnar nerve) is covered with a gel pad, and both arms are tucked in at the side of the patient. The beanbag is carefully cradled above both shoulders and around the arms to prevent the patient from falling while in extreme Trendelenburg. A gel pad covered by a towel is placed on the upper chest. Tape is placed under the bed, over each shoulder, and across ...

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