Until today, laparoscopic technique in Crohn's disease has been applied mainly in uncomplicated cases like enterostomy formations in anal disease or ileocecal resections in primary disease of the terminal ileum. The satisfying laparoscopic management of frequent complications as fistulas, abscesses or multiple strictures and of recurrent abdominal procedures has hardly been described.

Four different cases are presented. In recurrence after previous conventional surgery (case 1) as well as in entero-enteric fistula formation (case 2) and sealed perforation of an abscess with eventual bladder fistula (case 3), the surgical approach is very systematic. First, adhesions and fistualas are taken down to make an exploration of the complete bowel possible and to determine the real extent of all Crohn's lesions. If technically feasible the ileocolic vessels should be transected laparoscopically. After this, the bowel is mobilized laterally and eventual fistulas to the urinary bladder and towards the iliac fossa are separated. In most cases, a periumbilical minilaparotomy is appropriate to exteriorize the bowel without strong tension on the mesentery. Resection and hand-sewn end-to-end anastomosis are carried out in front of the peritoneal cavity. A special fourth case demonstrates laparoscopic-assisted resection of fistulizing bowel segments including harvest of a capsule camera, which had been stuck in front of an ileal stenosis.

In 21 laparoscopic-assisted operations in Crohn's disease, there were 8 reoccurences and/or preoperative complications had occurred like ileus, sealed perforations or abscesses (7) and fistulas (9) to the bladder or other bowel segments. In 14 cases, small and large bowel was resected, in 4 of these with extended segments of ileum or colon. In 5 cases, two separate segments of ileum and colon were resected. In 2 cases of recurrent Crohn's disease, only small bowel was resected, in one of them with 6 additional strictureplastics. The median length of the minilaparotomy was 5.5 cm (4.0-8.0). The median time of operation was very variable, with a median of 215 min (135-290). There were no intraoperative complications and no reoperations. The median length of hospital stay was 7 days (6-13).

Even complicated cases of Crohn's disease with previous surgery, fistulas, abscesses and sealed perforations may be treated safely by laparoscopic technique.