P. REISSMAN

whom am i speaking to hello yes we hear you well good morning thank you to be good to be with us

that we do from the ligament of trites underneath the transverse colon and then we run the intestine

as far as we can and the place that we arrive with this PDS and the loop we

know that from the trites until here the intestine you see this is the market we

put this is an absorbable thread and we put it like this so we know that from

the trites until here everything is okay and then we go to the site of the

pathology and what you can see here is the cecum and some some typical findings this is the cecum

here and this is the terminal ilium and you see here some typical findings of Crohn's disease

you see a very thick mesenteric fat that is creeping on top of the wall of the intestine

which we call creeping fat. The wall of the bowel here is very thick, congested, and here is some

adhesion to the abdominal wall, and this is probably the site of the previous abscess that

she had. You can compare normal small intestine, as you see here, to the Crohn's intestine. And

And very typical, the omentum is also adhesed to this area here.

Can you see us?

Yes, we have a very good image.

So what we will do now, we will try gently to mobilize this segment of diseased bowel.

And many times we find even a chronic abscess that is still there.

By the way, this patient was not drained.

Many times if the abscess is drainable, we would put the drain under CT or ultrasound guidance and operate on the patient only later.

It's very important also to keep the patient with Crohn's disease on an elemental diet.

and this is very helpful to reduce the inflammation and also to improve the nutritional state of the patient

because many of these patients are hypoalbuminemic and we prefer to operate on them when they are in a better nutritional condition.

Sometimes we also see some findings that were not seen on the imaging, like different type of fistula connection to other organs in the belly, like the urinary bladder, small bowel, large bowel, etc.

So, I think it's important that whenever we operate on patients with Crohn's disease,

we have to be ready for surprises, but we will see in a moment what's going on here,

and we'll see whether there is any evidence of a fistula.

Meanwhile, we see only this dense adhesion to the abdominal wall, which we will try to

to separate with a combination of sharp and blunt dissection. What we use for dissection

mainly here is, as you see, the harmonic scalpel. I think it's a very efficient tool, but of

course any other energy sources are effective and can be used efficiently and safely. Once

Once we will disconnect this adhesion gear, we will be able to continue the exploration

and mobilization of that part that needs to be resected.

Of course, as you know, if we see other areas with strictures, in order to save a resection,

we sometimes will perform a stricturoplasty and this way we don't have to resect too much intestine

and avoid the risk of short bowel syndrome.

Do you have any questions at this point?

Not for a moment.

What we also do before surgery is try to...

Excuse me?

Yes?

What do you think about intracorporeal anastomosis in the right colectomy?

This patient developed a few days ago some abdominal pains and we thought she was obstructed

and this is why we did start on her recently at EPN, but before that, since her last admission

with the abscess, she stayed at home on elemental diet.

What is your experience in IBD patients?

Really, I have now a big experience in IBD, for us it's a rare pathology, but I agree with you, when it's possible, we prefer our elementary diet.

diet, but personally sometimes you have a problem with this kind of diet, pain and diarrhea.

So frequently we associate the NPT with the alimentary diet.

You can see now, this is the patient, you see here the right ureter, you see the peristalsis,

I hope you can see. This is the application of aorta here. This is the IBD. We try to identify the ureter. Can you see the peristalsis now?

Yes, we see very well. You have very good images. What's your camera?

and sometimes we have to separate it from the meso of the transverse colon,

but in this case we have already enough mobilization.

The transverse incision, which they have to the external view,

we have the ability of internal and external view.

Interval abdominal under pressure.

Open the knee.

Interval abdominal under pressure.

We prefer to do a transverse incision.

splitting of the transverse abdominis muscle, this way...

You perform always open celluloscopy, didn't you?

Did you perform always open celluloscopy?

It's a matter of habit.

And also, you see those tape stitches,

prosthotic procedure without the need of an incision.

This is not always very easy

because sometimes the inflammatory mass is very large.

to make the incision a little bit longer, but here it's coming, yes, okay, so what you see now is the diseased portion of Crohn's, you see this is the terminal ilium, very narrow lumen, very thick mesentery, this is the iliocical valve, and this is the ascending column, the right column, which is okay, so this is the diseased portion,

Now, one of the interesting questions, when we do a resection for Crohn's disease, is

what will be the resection margin?

Back many years ago, it was thought that it's very important to get microscopic clear margin,

margin, but now we know that this really is not important, and we go by the macroscopic

appearance of the intestine, because it doesn't matter in terms of the recurrence rate whether

microscopically there is some involvement or not.

To ligate the mesenteric vessels, normally in Crohn's disease we prefer to do a suture

ligature and not a simple knot because the meso is fat and coming out so we do a normal time.

You can take the meso with other energy sources like the endogia or impact and other ligature

other sources. I don't think it makes much of a difference I think as many things in general

surgery, he's using what he likes, as long as he's doing his job okay.

So for small vessels, we use the harmonic as you can see, we will do stitches or...

but it's still some changes, so we prefer to go over here where this looks completely normal.

Good question. I can see that now we do nothing.

Before we prefer to the mechanical preparation but sometimes we had problem for the gas in the intestine and now we do nothing.

And you?

Did it change the incidence of complications, wound infection, etc., or you have the same incidence?

My experience was the same, just the same.

Well, as you know, this is a controversial issue, and also in our country, in Israel, several centers do not use any preparation at all.

I personally like to use preparations. I prefer to work when the intestine is empty and, you know, decompressed.

I agree that according to the literature, I think several studies even show that there is less safety complications when you don't do the bowel preparations.

I agree that, you know, this is a controversial issue, but personally, we here in our department

in Shavei Tzedek, Jerusalem, we use mechanical preparations for almost all cases.

I can also tell you that if I do solid organs like pancreatectomies, splenectomies, I also

give them some partial mechanical preparation, and I find it, you know, it's very neat to

to work in an abdomen that has no bowel dilatation

and everything is empty.

What I'm doing now is reinforcement of the tape line,

which is also probably not really necessary,

but I think in Crohn's patients

with a marginal nutritional status,

I sleep better at night when I do these stitches,

and this is why we do it.

I also put a couple of stitches on the other side of the anastomosis, as you will see in a moment.

Also, one of the problems is bleeding from the anastomotic side in patients with Crohn's.

We had several cases because of some edema of the intestine.

My impression was that the incidence of anastomotic size bleeding, as you see here, this can cause

sometimes significant bleeding in the post-operative period.

So I prefer to put in some sutures and this way achieve a little more hemostasis.

I agree with you and now I prefer to use the endo-GIA to perform lateral-to-lateral anastomosis

for the bleeding problem.

Well, you know, they now came out with some different size of scarfs with smaller size

staples, thinking that this will prevent the bleeding and prevent the leakage rate, etc.

This is, of course, not proven, but it will be interesting to see.

And what you see here also, which happens many times, is a hematoma.

Because of the congested vessels in the mesentery, we see it in patients with Crohn's,

and these hemostatic sutures are very helpful to reduce the size of this hematoma.

We'll put one more.

That's it.

looks ok, and we'll show you in a minute the specimen, we'll just run another static

suture line here. I wanted to ask you, when you do a right colectomy, do you always close

the mesenteric defect? No, never. Also in the right and the left.

And the left?

And the left.

Yes.

I think in the left side...

Just now we have two problems with the left colectomy with intra-abdominal hernia.

Oh, really?

Really.

Well, I agree that the incidence is very, very low, and what I'm doing is, if it's an

an oncology case with colon cancer on the right side. I do a high ligation of the mesenteric

vessels and take the right colic and the iliopolic as its origin. I think it's almost impossible

with such a small umbilical incision to close the defect. So I always leave it open. And

And actually, personally, I never had a case of internal hernia so far.

But I think this is also the experience of most colorectal surgeons.

I think when we were residents, they taught us that we must close the defect.

But this is probably not always true.

Again, this is a hemostatic switch.

One question, please.

Do we leave a drainage after a right colectomy?

No, no.

I leave drainage only in case of Crohn's when there is an active abscess, but in other cases we do not leave any drain.

Or if we do a pelvic dissection, then we also leave a drain.

What is your practice?

I agree with you, but I leave the drainage.

Like you, as you see before, I prefer to sleep.

APD. This is the anastomosis. It looks well vascularized, tension-free. Put it back in.

We will take out the wound protector, this will go back in, and now do the inspection

of the rest of the small bowel to make sure that there is no additional disease.

And you see, this is the mark that we put, we did a laparoscopic inspection, this was

before we started the communication with you, but you see, this means that from here all

All the way to the tribes, everything is normal.

And this is also normal.

So we will now start the closure.

We will do some irrigations.

Now if everything was okay during the dissection,

I don't do a re-insufflation normally.

I do only irrigation.

We'll switch you back now to the laparoscopic camera.

We always take a look at the port side, make sure there is not too much of bleeding, okay?

This is the port side, there is some wounding here, but this is not a problem.

Okay. Now what we prepare for you, until we will start the next case, first of all, if you have any questions about this case, I would be happy to answer.