The Portsmouth protocol for intra-operative ultrasound of the small bowel in Crohn’s disease

Introduction: Bowel preservation is paramount in Crohn’s disease surgery as affected patients are typically young adults at risk of having several abdominal surgical procedures during their lifetime. Intraoperative assessment of extent and location of Crohn’s disease is not standardised and is left to a mixture of surgeons ‘experience, tactile feedback, macroscopic appearance and preoperative imaging. The aim of this study was to describe the technical steps of a standardised protocol for intraoperative ultrasound assessment of the small bowel in patients undergoing surgery for ileocolonic Crohn’s Disease.

Technique: After laparoscopic mobilisation of the bowel a periumbilical incision is performed for extracorporeal division of the mesentery and the resection and anastomosis. A gastrointestinal consultant radiologist, with expertise in Crohn’s disease imaging and abdominal ultrasound performs the full intraoperative assessment of the small bowel, by applying directly on the bowel a sterile probe, prior to resection being performed by the surgeon. The bowel is assessed through the wound protector with a sterile technique and the length, location and number of segments is documented together with further quantitative assessment using the (MREnterography or ultrasound in Crohn’s disease) METRIC scoring guide.

Results: A step by step protocol for intraoperative ultrasound evaluation of the entire small bowel has been described.

Conclusions: A standardised approach to intraoperative evaluation of extent and location of Crohn’s disease is desirable. Intraoperative ultrasound may provide added value for assessment of proximal and multifocal Crohn’s disease.