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Ileocolic resection involves removal of the terminal ileum, and the cecum. This is not an oncological resection, and it is indicated for benign conditions such as Crohn’s disease of the terminal ileum. One of the major technical differences from a formal right hemicolectomy for cancer is that the right branch of the middle colic artery is not divided and the ileocolic pedicle is not divided close to its origin. In addition, the resection of the cecum/ascending colon is limited, because in most cases, the rest of the colon is normal. However, despite this fact, most cases require hepatic flexure mobilization in order to extract the colon from a midline incision in order to perform an extracorporeal anastomosis.
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PREOPERATIVE CONSIDERATIONS
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In most right-sided colon resections, ureteral stents are not needed; however, in cases where there is an inflammatory process in the right lower quadrant (RLQ) that is close to the ureters on preoperative imaging or is distorting the normal anatomy, it is prudent to use stents. Placing a ureteral stent will help identify the ureter intraoperatively and, if injury should happen, it will likely be recognized and repaired.
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Complete Evaluation of the Small Bowel
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All patients with Crohn’s disease should have a recent evaluation of the small bowel by either computed tomography enterography or magnetic resonance enterography. The following important information can be obtained from preoperative imaging that will help to plan the surgical intervention:
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The location of the pathology.
Type of the disease, either fistulizing or stricturing in nature.
The length of the diseased segment.
Presence of any fistula or any communication to other structures. If there is a fistula, then determine if the other structure is diseased (e.g. in the case of an ileo-sigmoid fistula).
Determining if there are any skips lesions, their location, and their distance from the index lesion.
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Full evaluation of the gastrointestinal tract is essential prior to surgery. Upper and lower endoscopy is needed to assess the disease distribution prior to surgery. Colonoscopy will show if there is any colonic involvement. In addition, in cases of ileo-sigmoid fistula, it will determine if the sigmoid colon is the primary site of Crohn’s colitis or is secondarily affected by the inflamed terminal ileum. This would help to manage this intraoperatively, in the former scenario, the patient might require formal sigmoid resection, whereas in the latter, a primary repair of the sigmoid colon will be sufficient. In addition, the preoperative colonoscopy is important to document that there is no disease in the right colon, where the anastomosis will take place. Demonstration of the lack of inflammation in the colon left behind after the surgery is important, especially in patients who get a diverting ileostomy at the time of surgery. It helps in differentiating between ...