Crohn’s disease (CD) is a chronic and idiopathic inflammation that can affect any part of the gastrointestinal tract. The terminal ileum is the most frequently involved site, and first diagnosis is generally made between the ages of 20 and 30 years. Surgery plays a very important role in the management of CD. 70% to 90% [1] of diagnosed patients eventually require surgery, usually for complications or failure of medical treatment. Approximately 40% to 50% of patients undergoing surgery are likely to need further operations within 10–15 years [2].

Laparoscopic colorectal surgery began in the early 90s and rapidly spread, gaining acceptance for different indications, both benign and malignant.

The reduction of postoperative pain, commonly experienced by laparoscopic patients, allows a faster mobilization and improves pulmonary function [3]; these factors can contribute to lower complications rates [4] and make patients’ recovery smoother.

Significantly faster resumption of bowel function, a shorter hospital stay, and a lower overall morbidity are included among the generally mentioned benefits of laparoscopic surgery [5–11]. It is well known that the use of opiate analgesics negatively affects recovery of gastrointestinal function [12]. Laparoscopic approach, probably due to both limited incision extension and bowel manipulation, reduces postoperative pain and morphine administration and leads to rapid resolution of paralytic ileus and discharge from hospital, respectively. Such results were reported also for inflammatory bowel diseases [13].

In particular, CD patients are potentially optimal candidates for laparoscopy because they are mostly young and potentially more concerned about body image and cosmetic results. The high risk of surgical recurrence is a further reason to preserve the integrity of the abdominal wall. Furthermore, laparoscopic surgery might induce less adhesions [14], and since CD patients may undergo repeated surgery during their lives, this means lower risk of surgery for subocclusion. In case of need of subsequent surgery, the resulting operation used to be much easier.

In recurrent CD, the diffusion of laparoscopy was limited by objective technical difficulties and disease-related factors as fragility of inflamed, thickened mesentery and loops, presence of inflammatory masses or abscesses, fistulas, and massive adhesions.

Several studies, including four randomized trials [5, 6, 15, 16] and three meta-analyses [17–19], demonstrated the benefits of laparoscopy for primary small bowel CD regarding short-term outcomes such as postoperative pain, use of medication, complication rates, return to normal bowel habits, hospital stay, and cosmesis. For these reasons, laparoscopy in primary CD is nowadays considered the first choice treatment in most referral surgical centers.

The mean conversion rate reported in the current literature is 11.2% and ranges from 4.8% to 29.2% [17]. The duration of surgery for laparoscopic ileocolic resection can be very similar to open surgery after completion of the learning curve by the surgical team [6, 20, 21].

The safety of laparoscopic ileocolectomy has been proven also in the long-term outcomes by Eshuis and colleagues [22].

Today, surgeons refined their laparoscopic technical skills and got the help of new-generation instruments; indications for CD surgery broadened from uncomplicated ileocaecal resection or simple stoma formation to more complex procedures, even for recurrent disease.

Another major improvement in colorectal surgery has been represented by the introduction of a fast-track perioperative care program, also referred to as enhanced recovery after surgery (ERAS) [23, 24], which may reduce hospital stay to 2-3 days after open colorectal surgery [25, 26], even if high readmission rates are reported [25, 27]. Only a few studies evaluated the role of the laparoscopic approach combined to fast-track protocols in enhancing recovery after colorectal surgery and report conflicting results. Basse et al. [28] found no difference between fast-track patients undergone laparoscopic or open resection, while King et al. [29] found a significant reduction of the hospital stay in fast-track patients after laparoscopic surgery. The only randomized, multicentric clinical trial (LAFA study) [30] that investigated both surgical technique (laparoscopic and open) combined with fast-track and standard care demonstrated that the best option is laparoscopic resection embedded in a fast-track care procedure. All studies on laparoscopy and enhanced recovery protocols are focused on colon cancer and have not been validated yet in patients with inflammatory bowel disease, which may have a very different immunologic background.

Laparoscopic surgery represents a widely accepted option for selected CD patients: a broad spectrum of procedures, from simple to very complex, can be technically performed. The main accepted indication remains today ileocecal resection for primary uncomplicated CD.

In summary, even if evidence is lacking and more contributions with larger sample size are needed, the limited experiences available from the literature confirm that the laparoscopic approach to recurrent CD should not be avoided in principle; despite high technical difficulty, in hands of IBD surgeons with a deep expertise in laparoscopic surgery, it can be feasible, safe and lead to significant advantages in the postoperative period.

Laparoscopy for recurrence will be more often proposable in the near future, due to the increasing number of ileocecal resections already performed by laparoscopy for primary CD.