Abstract
-
Purpose
- Ileocecal tuberculosis (ICT) presents unique surgical challenges due to dense adhesions, distorted anatomy, and inflamed tissue planes. Although laparoscopic right hemicolectomy (LRH) is well established in colonic surgery, its application in ICT remains limited. We evaluated the feasibility and outcomes of the caudal tunneling with lateral colonic attachment preservation (CLAP) procedure, a modified laparoscopic technique designed to facilitate safer dissection in ICT.
-
Methods
- This single-center prospective cohort study was conducted between May 2016 and October 2023 at King George’s Medical University. Fifty-six adult patients with confirmed ICT underwent LRH using the CLAP technique. The procedure begins with retroperitoneal tunneling along Toldt fascia from the terminal ileum while preserving lateral colonic attachments until the final step. Intraoperative variables, perioperative outcomes, and complications were recorded. Patients were followed for 2 years to assess long-term outcomes.
-
Results
- The median age was 38 years, and 64.3% of patients were female. Dense adhesions were noted in 87.5% of cases. The mean operative time was 181 minutes (mean blood loss, 100±20 mL). Conversion to open surgery occurred in 3 patients (5.4%). Additional ports were required in 80.4%. Morbidities included prolonged ileus (10.7%), surgical site infection (5.4%), urinary tract infection (12.5%), and anastomotic leak (1.8%). There was no mortality. At 2-year follow-up, all patients demonstrated symptom resolution and weight gain, with 1 incisional hernia reported.
-
Conclusion
- The CLAP technique is a safe and feasible modification of LRH for ICT, enabling controlled retroperitoneal dissection and minimizing operative risk. Larger multicenter comparative studies are warranted.
-
Keywords: Tuberculosis; Colectomy; Minimally invasive surgical procedures; Treatment outcome
INTRODUCTION
Ileocecal tuberculosis (ICT) is a common gastrointestinal manifestation of tuberculosis, particularly in the Indian subcontinent. It presents with a wide range of symptoms, including anemia, altered bowel habits, weight loss, abdominal pain, abdominal mass, and, in severe cases, subacute or acute intestinal obstruction and perforation [1]. The inflammatory nature of ICT, along with associated fibrosis and adhesions, often complicates surgical management, making it a technically demanding procedure.
Laparoscopic colorectal surgery is now well established as a safe and effective approach for both benign and malignant diseases [2]. Multiple controlled studies and meta-analyses have demonstrated its advantages over conventional open surgery, including reduced postoperative pain, faster return of bowel function, and shorter hospital stay. While extensive literature exists on laparoscopic colonic resection for malignancy, evidence for its application in benign conditions such as ICT remains limited. Most Western studies focus on laparoscopic management of inflammatory bowel disease and diverticular disease, with little emphasis on ICT [3].
Laparoscopic right hemicolectomy (LRH) is infrequently performed for ICT due to inherent challenges, including dense intra-abdominal adhesions, anterior cecal fixation, a pulled-up cecum, a shortened and thickened mesocolon, and difficulty in identifying the ileocecal vascular pedicle. These anatomical distortions add complexity and risk, often necessitating technical modifications to standard laparoscopic approaches.
To address these challenges, we developed the caudal tunneling with lateral colonic attachment preservation (CLAP) procedure. This approach begins with mesenteric mobilization at the unaffected terminal ileum, allowing safe creation of a retroperitoneal tunnel along Toldt fascia while preserving the lateral colonic peritoneal attachment until retroperitoneal dissection is complete.
This study evaluated the feasibility, technical modifications, safety, and perioperative outcomes of the CLAP procedure for laparoscopic resection of the diseased ileocecal region in patients with ICT. While both medial-to-lateral and lateral-to-medial approaches have been described for malignant and selected benign colonic diseases, systematic outcome data on this modified approach in the particularly challenging setting of ICT are lacking.
METHODS
Ethics statement
This study was approved by the Institutional Review Board of King George's Medical University (No. 76th ECM II-B_Thesis/P21). Written informed consent for publication of the research details and clinical images was obtained from all patients included in the study after preoperative evaluation. All study procedures were conducted in accordance with the principles of the Declaration of Helsinki.
Study setting and patients
This single-center prospective cohort study was conducted in the Department of Surgical Gastroenterology, King George’s Medical University from May 2016 to October 2023.
The inclusion criteria for this study were as follows: (1) adult patients between 18 and 65 years of age; (2) with a confirmed diagnosis of ICT based on clinical presentation, radiological imaging, microbiological, and/or histopathological findings; (3) medically fit for elective laparoscopic surgery under general anesthesia, classified as American Society of Anesthesiologists (ASA) physical status I to III; and (4) with a history of recurrent or chronic ICT-related symptoms, such as subacute intestinal obstruction, who had been adequately managed with conservative treatment prior to surgery.
The exclusion criteria were the following: (1) patients with malignancy involving the ileocecal region, whether diagnosed before or during surgery; (2) those requiring emergency surgery due to obstruction, perforation, or hemodynamic instability; (3) patients with a history of extensive prior abdominal surgery that contraindicated laparoscopy; (4) those with ASA physical status IV or higher, severe comorbid conditions, immunosuppression, pregnancy, or (5) unable or unwilling to provide informed consent.
Preoperative evaluation
All patients underwent a comprehensive clinical assessment, including detailed medical history, physical examination, and laboratory investigations such as complete blood count, liver and kidney function tests, blood glucose levels, and erythrocyte sedimentation rate. Radiological evaluation included a chest x-ray and contrast-enhanced computed tomography of the abdomen to assess disease extent and exclude complications. Diagnosis was confirmed microbiologically and histopathologically using the QuantiFERON-TB Gold (QFT) test (Qiagen) and colonoscopic biopsy. Colonoscopy with biopsy was routinely performed to identify characteristic mucosal features.
Surgical technique
The procedure was performed using standard 4-port laparoscopic access. The umbilical port served as the camera port, the supraumbilical port as the assistant port, the left iliac fossa port as the working port, and an accessory port was placed in the right iliac fossa. Additional modifications were made as required based on intraoperative findings (Fig. 1). The CLAP procedure was initiated by mobilizing the mesentery at the unaffected terminal ileum. The terminal ileum was lifted cranially to identify a disease-free dissection plane. Dissection was carried out in the retroileal space caudally, creating a safe tunnel along Toldt fascia while preserving the lateral colonic attachments until retroperitoneal dissection was complete (Fig. 2). This approach facilitated early identification of critical retroperitoneal structures, including the duodenum, Gerota fascia, pancreas, liver, right ureter, and superior mesenteric vessels, thereby minimizing the risk of inadvertent injury (Fig. 3).
Meticulous adhesiolysis was performed in cases with dense anterior abdominal wall adhesions. Colonic and mesenteric mobilization proceeded along the mesocolic plane until the undersurface of the liver and gallbladder was visualized. Vascular pedicles were ligated close to the bowel to ensure hemostasis while preserving the integrity of the mesocolic plane. The specimen was retrieved through a small midline incision, and bowel continuity was restored using a side-to-side extracorporeal ileocolic anastomosis with a linear stapler.
Operative records and postoperative follow-up
Operative data, including intraoperative findings, extent of adhesions, duration of surgery, blood loss, difficulty in identifying the ureter, need for additional ports, and conversion rates, were systematically documented. Postoperative morbidity was classified according to the Clavien-Dindo classification, while postoperative mortality was defined as any death occurring within 30 days of surgery. All patients continued their antitubercular therapy (ATT) regimen for 6 months after surgery. Long-term follow-up was maintained for over 2 years through outpatient visits and telephonic consultations. During follow-up, assessments focused on symptom resolution, weight gain, recurrence of obstructive symptoms, development of incisional hernias, and adherence to ATT.
Statistical analysis
Patient characteristics were summarized using appropriate descriptive statistics. Continuous parametric data were presented as mean±standard deviation, and categorical variables were expressed as absolute numbers and percentages. All statistical analyses were performed using IBM SPSS ver. 20 (IBM Corp).
RESULTS
Patient demographics
Of the initial 254 patients diagnosed with intestinal tuberculosis, 198 were excluded due to nonoperative management (n=128), emergency presentations (n=51), or the presence of a cocoon abdomen (n=19). Consequently, a total of 56 patients diagnosed with ICT underwent elective laparoscopic right hemicolectomy using the CLAP procedure and were included in the final analysis (Supplementary Fig. 1). Conversion to open surgery was required in 3 patients due to extensive adhesions and technical difficulties. Among the cohort, 20 (35.7%) were male and 36 (64.3%) were female, with a median age of 38 years at presentation (Table 1).
Clinical presentation
The most common presenting symptom was abdominal pain (n=50, 89.3%), and 21 patients (37.5%) had a history of recurrent episodes of subacute intestinal obstruction. Other symptoms, such as rectal bleeding and altered bowel habits, were less frequently reported. Notably, 25 patients (44.6%) had received ATT prior to surgery.
Perioperative outcomes
The mean operative time was 181 minutes. Intraoperative adhesions, including bands, interbowel adhesions, omental migration, and retroperitoneal fibrosis, were observed in 49 patients (87.5%). The mean intraoperative blood loss was 100±20 mL. Due to technical challenges, 45 patients (80.4%) required the placement of an additional port to enhance visualization and maneuverability. No patient required creation of a stoma (Table 2).
Postoperative course and complications
Nasogastric tubes were typically removed on postoperative day 1, and most patients were able to initiate oral liquid intake the same day. Injectable analgesics were required for an average of 3 days, after which most patients transitioned to oral analgesics that were discontinued within 4 to 5 days. No postoperative mortality occurred.
Histopathological examination confirmed tuberculosis in all patients, and all were prescribed a 6-month ATT regimen. However, 3 patients (5.4%) were unable to complete the course due to noncompliance or adverse drug reactions.
Postoperative complications were observed in a minority of patients. Superficial surgical site infections occurred in 3 patients (5.4%) and were managed with drainage and regular dressing. Paralytic ileus developed in 6 patients (10.7%) and was resolved with conservative management. One patient (1.8%) experienced an anastomotic leak that required reoperation with peritoneal lavage and the creation of a loop ileocolostomy, which was reversed within 8 weeks.
Additionally, urinary tract infections occurred in 7 patients (12.5%), and chest complications were observed in 3 (5.4%); both were managed conservatively. Intra-abdominal collections developed in 2 patients (3.6%) and were treated successfully with percutaneous drainage. No patients experienced cardiac complications or required readmission (Table 3).
Operative outcomes and follow-up
Over the 2-year follow-up period, all patients demonstrated symptom resolution and weight gain, with no recurrence of obstructive symptoms. One patient developed an incisional hernia, which was repaired through an open surgical approach. Additionally, 3 patients did not adhere to the ATT regimen: 2 due to residence in remote areas and 1 who was lost to follow-up (Table 4).
DISCUSSION
Laparoscopic colorectal surgery has evolved from a cautious novelty into a widely accepted standard over open techniques, owing to its well-established advantages, including reduced postoperative pain, shorter hospital stays, improved cosmetic outcomes, fewer wound-related complications, and overall enhancement in quality of life. Since the first LRH was reported in 1991, multiple operative approaches have been described—namely, medial-to-lateral, lateral-to-medial, top-down, and bottom-up techniques [5]. Among these, the medial-to-lateral approach is generally preferred because it is associated with shorter operative times and a lower risk of conversion to open surgery [6]. However, its application in benign inflammatory conditions such as ICT has remained limited. This hesitation is understandable: dense anterior abdominal wall adhesions, a pulled-up cecum, thickened mesocolon, and complex vascular anatomy can transform what initially appears to be a standard right hemicolectomy into a technically demanding, high-risk dissection.
It was within this context that Professor Abhijit Chandra conceptualized and implemented a modification of the medial-to-lateral approach to address these specific challenges. This modification, termed the CLAP procedure, begins with elevation of the terminal ileum and incision of Toldt fascia. The key principle is to preserve the lateral peritoneal attachments of the colon until the final stage of mobilization. Dissection starts in the retroileal space, creating a safe tunnel along Toldt fascia. This early caudal tunneling enables identification of key retroperitoneal structures, including the ureter, gonadal vessels, duodenum, pancreas, and superior mesenteric vein, before manipulating the inflamed bowel, thereby minimizing the risk of inadvertent injury.
The CLAP approach differs from the conventional medial-to-lateral technique, in which dissection usually begins above the ileocolic vessels to permit early vascular ligation, followed by progressive anterior mobilization of the right mesocolon over the duodenum and along Toldt fascia. This conventional sequence can occasionally result in duodenal injury in cases of a pulled-up cecum or cicatrized mesentery. In contrast, CLAP preserves both medial and lateral attachments during the initial stages, simplifying mesocolic separation from Toldt fascia and maintaining effective traction–countertraction throughout the dissection.
It also differs from the initial retrocolic endoscopic tunnel approach (IRETA) technique described by Subbiah et al. [7] for complete mesocolic excision in right colonic cancers. In IRETA, dissection begins at the cecal peritoneal reflection and proceeds across the small bowel mesentery in a retrocolic plane toward the mesenteric root, allowing central vascular ligation. While IRETA provides excellent retrocolic visualization for oncologic resections, it involves early division of peritoneal attachments—a step that is less suitable for benign inflammatory pathology such as tuberculosis, where tissue planes are scarred and distorted. In contrast, CLAP delays division of lateral peritoneal attachments, avoiding premature disruption of peritoneal planes and enabling a more controlled, anatomy-guided dissection in the presence of adhesions and altered vascular orientation.
When contextualized with existing literature, Balsara et al. [3] reported 26 laparoscopic-assisted ileocolic resections for ICT with a morbidity rate of 15%, surgical site infection rate of 11.5%, and mean hospital stay of 5.6 days. In our prospective CLAP series, overall morbidity was slightly lower at 10.7%, the surgical site infection rate was halved to 5.4%, and the median hospital stay was comparable at 5 days, despite dense adhesions in 87.5% of patients.
In Crohn disease, Chebbi et al. [8] described a total retromesenteric approach in 89 patients, reporting shorter mean operative times (130 minutes) but higher blood loss (200 mL) and a 13.6% conversion rate. In contrast, our mean operative time was longer (181 minutes), but blood loss was lower (100±20 mL), and the conversion rate was smaller (5.4%). Although disease profiles differ, both techniques share the principle of early, structure-oriented retroperitoneal dissection. The CLAP modification adapts this concept to ICT by initiating dissection below the ileocolic vessels while preserving lateral attachments. Similarly, Makni et al. [9] compared laparoscopic-assisted and open ileocolectomy for Crohn disease, reporting a 14% conversion rate and a mean postoperative stay of 6.7 days. In contrast, CLAP achieved a lower conversion rate and shorter hospital stay, likely due to improved exposure and safer tissue handling enabled by early caudal tunneling.
Finally, in their systematic review of abdominal tuberculosis, Di Buono et al. [10] noted that laparoscopy was used in only 5% of cases, primarily due to concerns regarding adhesions and emergency presentations. Our ability to complete 94.6% of resections laparoscopically, with acceptable morbidity and zero mortality, directly challenges this reluctance and demonstrates that, when performed in a structured sequence, minimally invasive surgery is both feasible and advantageous for selected ICT patients.
Conclusions
Our findings suggest that the CLAP approach enhances surgical safety by facilitating early identification of the avascular plane before vascular pedicle ligation, thereby reducing the risk of injury to the duodenum, ureter, pancreas, and major vessels. Performing ligation close to the colon or ileum further improves safety in the inflamed, adherent planes characteristic of ICT. Although the results are encouraging, this study’s main limitation lies in its relatively small sample size and lack of a control group. Larger, multicentric comparative studies are warranted to validate these findings and establish the relative advantages of the CLAP method over other established LRH techniques for ICT.
ARTICLE INFORMATION
-
Conflict of interest
No potential conflict of interest relevant to this article was reported.
-
Funding
None.
Supplementary materials
Supplementary material are available from https://doi.org/10.3393/ac.2025.00794.0113.
Fig. 1.Port placement for the caudal tunneling with lateral colonic attachment preservation (CLAP) procedure. Standard 4-port configuration with an additional port (if required) placed in the left lower quadrant for improved visualization and maneuverability.
Fig. 2.Caudal tunneling approach in the caudal tunneling with lateral colonic attachment preservation (CLAP) procedure. Dissection initiated below the ileocolic vessels into the retroileal space, creating a tunnel along Toldt fascia before mobilization of lateral peritoneal attachments.
Fig. 3.Intraoperative view of preserved lateral colonic attachments with retroperitoneal structures.
Table 1.Baseline characteristics of the study population (n=56)
|
Characteristic |
Value |
|
Age (yr) |
38 (18–46) |
|
Sex |
|
|
Male |
20 (35.7) |
|
Female |
36 (64.3) |
|
Body mass index (kg/m2) |
17 (15–21) |
|
ASA physical status |
|
|
I |
36 (64.3) |
|
II |
17 (30.4) |
|
III |
3 (5.4) |
|
Previous abdominal surgery |
6 (10.7) |
Table 2.Surgical and pathological outcomes (n=56)
|
Variable |
Value |
|
Operative time (min) |
181±SD |
|
Blood loss (mL) |
100±20 |
|
Conversion to open procedure |
3 (5.4) |
|
Intraoperative complications |
2 (3.6) |
|
Intraoperative adhesion |
49 (87.5) |
|
Ureter identification difficulty, |
4 (7.1) |
|
Need for additional ports |
45 (80.4) |
|
Hospital stay (day) |
6 |
Table 3.Complications and outcome (n=56)
|
Postoperative complication |
No. of patients (%) |
|
Prolonged ileus |
6 (10.7) |
|
Surgical site infection |
3 (5.4) |
|
Anastomotic leak |
1 (1.8) |
|
Urinary tract infection |
7 (12.5) |
|
Chest complications |
3 (5.4) |
|
Cardiac complications |
0 (0) |
|
Intra-abdominal collection |
2 (3.6) |
|
Re-laparotomy |
1 (1.8) |
|
30-Day readmission |
0 (0) |
Table 4.Follow-up outcomes over 2 years (n=56)
|
Outcome |
No. of patients (%) |
|
Symptom resolution |
56 (100) |
|
Weight gain |
56 (100) |
|
Recurrence of obstructive symptom |
0 (0) |
|
Incisional hernia formation |
1 (1.8) |
|
Adherence to antitubercular treatment |
53 (94.6) |
REFERENCES
- 1. Tobin EH, Khatri AM. Abdominal tuberculosis. In: StatPearls [Internet]. StatPearls Publishing; [updated 2025 Feb 6; cited 2025 Jan 1]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556115/
- 2. Agresta F, Arezzo A, Allaix ME, Arolfo S, Anania G. Current status of laparoscopic colorectal surgery in the emergency setting. Updates Surg 2016;68:47–52. ArticlePubMedPDF
- 3. Balsara KP, Shah CR, Maru S, Sehgal R. Laparoscopic-assisted ileo-colectomy for tuberculosis. Surg Endosc 2005;19:986–9. ArticlePubMedPDF
- 4. Ribeiro U Jr, Tayar DO, Ribeiro RA, Andrade P, Junqueira SM Jr. Laparoscopic vs open colorectal surgery: Economic and clinical outcomes in the Brazilian healthcare. Medicine (Baltimore) 2020;99:e22718.ArticlePubMedPMC
- 5. Bae SU, Saklani AP, Lim DR, Kim DW, Hur H, Min BS, et al. Laparoscopic-assisted versus open complete mesocolic excision and central vascular ligation for right-sided colon cancer. Ann Surg Oncol 2014;21:2288–94. ArticlePubMedPDF
- 6. Buia A, Stockhausen F, Hanisch E. Laparoscopic surgery: a qualified systematic review. World J Methodol 2015;5:238–54. ArticlePubMedPMC
- 7. Subbiah R, Bansal S, Jain M, Ramakrishnan P, Palanisamy S, Palanivelu PR, et al. Initial retrocolic endoscopic tunnel approach (IRETA) for complete mesocolic excision (CME) with central vascular ligation (CVL) for right colonic cancers: technique and pathological radicality. Int J Colorectal Dis 2016;31:227–33. ArticlePubMedPDF
- 8. Chebbi F, Ayadi MS, Rhaiem R, Daghfous A, Makni A, Rebaϊ W, et al. Laparoscopic ileo-cecal resection: the total retro-mesenteric approach. Surg Endosc 2015;29:245–51. ArticlePubMedPDF
- 9. Makni A, Chebbi F, Ksantini R, Fétirich F, Bedioui H, Jouini M, et al. Laparoscopic-assisted versus conventional ileocolectomy for primary Crohn's disease: results of a comparative study. J Visc Surg 2013;150:137–43. ArticlePubMed
- 10. Di Buono G, Romano G, Amato G, Barletta G, Romano G, Adelfio N, et al. Surgical management of complicated abdominal tuberculosis: the first systematic review: new treatments for an ancient disease and the state of the art. J Clin Med 2024;13:4894.ArticlePubMedPMC
Citations
Citations to this article as recorded by
KSCP
APFCP
SIUCP-ETS
NSCRD
SCRS
, Utkarsh Srivastava
Cite this Article
XML Download
