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The cost of inflammatory bowel disease (IBD) treatment has been sparsely investigated, and drivers of cost in patients with IBD include pharmacotherapy, hospital admissions, emergency department visits, and surgical treatment. The high economic burden of IBD is thought to be tied to the complex and chronic nature of the disease, especially as Crohn’s disease, and ulcerative colitis patients often require a combination of medical and surgical therapy. Patients with IBD commonly receive lifelong care from a limited number of providers, with potentially high costs of treatment. This makes IBD a candidate for a specialty medical home that aims to provide patients with accessible, inclusive, and well-coordinated patient-centered care. This IBD specialty medical home (IBD SMH) functions as a smaller team of providers with one provider, acting as the patients’ main point of contact, who takes the role of coordinating patients’ acute and chronic care. This chapter will focus on the role of the IBD SMH and its role in the care of patients with IBD.

Anal intraepithelial neoplasia (AIN) is a pre-malignant lesion that may progress to anal carcinoma. Though rare, anal cancer results in high morbidity, especially if resection is required. Due to its frequent association with human papilloma virus (HPV) infection and indolent pre-malignant dysplasia, there is potential for prevention with vaccination and opportunity for early detection through screening, thorough examination, and active surveillance. However, AIN is often incidentally discovered during unrelated procedures and should be biopsied for accurate diagnosis and appropriate treatment. Due to wound failure and significant morbidity, extensive resection of AIN and malignancy is often no longer recommended as first-line standard treatment. Pre-malignant lesions are typically managed medically, with focused operations and then observed. Chemoradiation therapy is the typical first line of treatment when anal cancer is diagnosed; while surgery is indicated in persistent or recurrent cases.

Ureteral injuries can have devastating consequences for the patient. Unfortunately, patient- and disease-related factors can create conditions difficult for proper identification. Here we review some methods to help identify the ureter.

One hallmark of Crohn’s disease is a large, edematous, and friable mesentery. Depending on the degree of involvement, several different methods may be required to ensure adequate hemostasis. This chapter will discuss various options.

Thoughtful preoperative preparation is necessary prior to performing transanal total mesorectal excision (TaTME) whether it be for benign or malignant disease. Evaluation begins with a careful history and thorough physical examination. Additionally, the patient’s entire past medical and surgical history should be reviewed along with a detailed assessment of the patient’s current medications. Several preoperative tests are necessary regardless of etiology, and stringent oncologic principles must be followed in the preoperative staging of patients with malignant disease. Irrespective of the indication for surgery, a careful preoperative risk assessment must be performed and may warrant additional testing for cardiopulmonary fitness. Routine laboratory workup and imaging should be individualized for each patient. An enhanced recovery after surgery (ERAS) protocol should be implemented in the preoperative, intraoperative, and postoperative care of the patient. Care must be taken to ensure individual patient factors are taken into consideration with utilization of each element of the pathway.

In very thin patients with a thin abdominal wall, avoiding cannula slippage can be challenging as the subcutaneous tissues help hold the trocar in place. In addition, significant amounts of torque placed on the trocar during the operation can increase the size of the fascial defect. When the cannula slips out, it can be difficult to find the original tract to re-place it. This problem can add time to the surgery and can be frustrating when it occurs repeatedly. In this chapter we will review methods to help with avoiding or managing dislodged cannulas.

Ileal pouch-anal anastomosis (J pouch) has become the standard restorative procedure following total proctocolectomy. Yet, lengthening maneuvers to ensure an adequate tension-free anastomosis are crucial to minimizing complications and ensuring appropriate pouch function. This chapter will discuss what steps to take should the pouch not reach.

Ileocolic and ileorectal anastomoses may be completed intracorporeally or extracorporeally. One of the potential complications that can occur is a twisting of the mesentery leading to vascular compromise or obstruction.

Pelvic surgery brings about additional potential difficulties due to the fixed bony pelvis and the adjacent vascular, neurologic, and genitourinary structures. Further, patient- and disease-related factors such as large tumors, obesity, prior radiation, inflammation, and recurrent disease make a laparoscopic approach technically demanding. Here we will review how to approach the rectal dissection via minimally invasive surgery.

Leaving too long of a rectal cuff with a total proctocolectomy and J-pouch can lead to problems associated with residual inflammation (cuffitis) and emptying problems. This chapter will evaluate what to do in the patient with the long residual rectal cuff.

Crohn’s disease (CD) is an idiopathic chronic inflammatory condition affecting the gastrointestinal tract anywhere from the mouth to the anus and is characterized by transmural inflammation that leads to penetrating complications. As a result, about one-third of Crohn’s disease patients have internal fistulas over the course of their life. Fistulas are abnormal communications between two epithelial surfaces, and patients with Crohn’s disease may suffer from different types of fistulas: anorectal, enterovesical or colovesical, enterovaginal or rectovaginal, enteroenteric or enterocolic, and enterocutaneous fistulas. Entero-urinary fistulas are a relatively uncommon, yet challenging, complication of Crohn’s disease. Our understanding of fistulas to the urinary tract is incomplete, and strategies to manage these fistulas remain somewhat controversial. Epidemiological data on entero-urinary fistulas are contradictory, with published studies reporting highly variable incidence rates, ranging from 1.7% to 7.7%. Entero-urinary fistulas are most commonly diagnosed based on clinical symptoms, although diagnostic tests such as cystoscopy, computerized tomography (CT) scan, magnetic resonance imaging (MRI), upper gastrointestinal contrast studies with small bowel follow-through, barium enema, and colonoscopy are often necessary to confirm the fistula. At present, there is no uniform agreement on the optimal diagnostic algorithm, although certain principles remain.

Rectal cancer remains a common and complex surgical problem. Owing to several landmark trials, such as the COST trial, the use of minimally invasive technology for the resection of colon cancer is now widely accepted as a feasible alternative to open surgery. The use of minimally invasive surgery (MIS) for the treatment of rectal cancer, however, is a separate entity and continues to be a matter of debate. Many innovative new technologies are being developed and implemented, and there is mounting evidence supporting the use of MIS for the treatment of rectal cancer. This chapter explores the evidence regarding the short- and long-term outcomes of MIS for rectal cancer, as well as currently available techniques and barriers to implementation.

Splenic flexure mobilization may be a routine or selective part of left-sided operations. Understanding tips and tricks used in the most difficult flexure takedown is a critical component to minimize complications.

Exposure is critical to having safe surgery and overall patient assessment—especially in the operating room. When providing a consult in the operating room, ensure you have the optimal exposure and/or approach that meets your needs. Here we evaluate an overview of a few common scenarios and tricks when confronted with an intraoperative consult.

Colon and rectal surgery has witnessed a vast increase in both the use of and subsequent publications about single-incision laparoscopic surgery (SILS). While single-incision surgery goes by several different names, it is important to keep in mind that when learning any new approach, the operative procedure (with regard to safety and outcomes) should remain the same. Although there is a learning curve that each surgeon must complete and overcome in order to become proficient, the patient should not suffer in the interim. With regard to colon and rectal surgery, special populations such as those with inflammatory bowel disease, diverticulitis, large tumors, and other inflammatory disorders may present technical challenges for open as well as other minimally invasive approaches. Therefore, it is especially important when selecting the operative approach to match it to the individual patient at hand, as well as being realistic about one’s technical expertise and experience with a particular procedure. In this chapter, we will highlight the unique challenges of single-incision surgery, discuss general patient selection and consideration issues, and examine how this approach relates to those particular cohorts such as those with inflammatory bowel disease and obesity.

Effective colonoscopy is dependent on adequate bowel cleansing. A number of bowel preparation regimens have been advocated, with the gold standard being polyethylene glycol and balanced electrolytes. Nevertheless, a number of lower volume preparations have been adopted in hopes of increasing tolerability without sacrificing efficacy. More aggressive bowel preparations have been suggested for those at high risk for inadequate bowel cleansing. Techniques such as endoscopic jet lavage may be used to salvage an inadequate preparation; however, these methods are somewhat costly in terms of time. The adequacy of the preparation should be documented according to a validated cleansing scale.

Performing surgery is often difficult. Performing surgery under fire is arduous at best. Furthermore, operating in dangerous or austere environments adds stressors uncommon to usual civilian practice. Yet, even for those surgeons that may never experience combat, circumstances may arise that can mimic this experience. As such, this chapter is applicable to all surgeons, especially in the world today, and outlines what a surgeon should consider when faced with taking care of an injured patient in less than ideal situations. There is much more to think about when dealing with traumatic injuries in an environment that is unsafe for all involved. While priority is always placed on treatment of the patient’s injuries, with the goals of saving life and limb, a surgeon operating under these conditions must also ensure his or her safety, as well as the safety of his or her team.