A case of fistulating disease involving the terminal ileum and sigmoid colon-A video vignette.

Abstract

This video presents a case involving complex inflammatory bowel disease (IBD) with fistulation of the terminal ileum and sigmoid colon. We aim to discuss an overview of the decision-making involved in the pre-operative, intra-operative and post-operative stages, while highlighting the benefits of utilising a robotic platform. A 29-year-old patient with Crohn's disease underwent a robotic ileo-colic resection without anastomosis and double barrel ileostomy formation. A multidisciplinary approach was taken with regard to surgical planning. Pre-operative dietician and gastroenterology input optimised nutritional status and continued biologic therapy. Involvement with radiology was key; an MRI for surgical planning was reviewed in combination with the radiologist to determine the nature of the disease. The intra-operative video discusses factors pertaining to robotic surgery, including port placement and extraction site planning. The salient intra-operative stages are highlighted, and nuances of IBD-specific robotic techniques are discussed. The importance of pre- and intra-operative factors in IBD surgery is explored; biologic and steroid use, nutritional status, exclusive enteral nutrition, consideration for fistulating disease and adapting ports to stoma and extraction sites. Post-operative surveillance is discussed, including current practice with tattooing and severity scores, in addition to ongoing research utilising artificial intelligence to improve the ability to detect recurrence. This video presents a case of an ileo-sigmoid fistula related to Crohn's disease. Optimisation strategies for the pre-operative, intra-operative and post-operative phases are discussed. The benefits of a robotic platform with respect to the challenges of IBD surgery are demonstrated.