# Need help with this colectomy/colovesicular fistula...



## bda23054 (Nov 21, 2012)

PREOPERATIVE DIAGNOSIS
Sigmoid diverticulosis with colovesical fistula.

POSTOPERATIVE DIAGNOSIS
Sigmoid diverticulosis with colovesical fistula.

NAME OF OPERATION
Hand-assisted laparoscopic sigmoid colectomy with take down of colovesicular fistula

SPECIMEN
Sigmoid colon.

FINDINGS 
Upon establishment of pneumoperitoneum, the patient was noted to have quite a few adhesions of the sigmoid colon to the anterior lateral abdominal pelvic wall over the pelvic brim.  As these were taken down into the preperitoneal space, a tract was noted attaching the sigmoid colon to the bladder to the left side.  There was no visible bladder mucosa.  It appeared to be a thin tract that on dilation of the bladder later in the case did not have any leakage.  Reanastomosis after the sigmoid colon was removed had no tension on it, and the patient had a smooth liver with no isolated lesions.  No acute inflammatory changes appreciated within the intraabdominal cavity.  The sigmoid colon however, was thick and consistent with chronic diverticulosis and intermittent diverticulitis.  The small bowel was grossly normal.  The patient did have a history of hysterectomy.  This was consistent with findings of surgically absent ovaries and uterus.   

DESCRIPTION OF OPERATION
The procedure as well as indications, benefits and potential risks were explained to the patient.  All questions were answered.  With consent obtained, the patient was taken to the Operative Suite, placed in the supine position and general anesthesia initiated.  The patient was then placed up in a lithotomy position and Dr. Dixon performed cystoscopy with ureteral stent placements that can be found dictated separately.  The patient was then placed in a low lithotomy position.  Anterior abdominal wall was prepped and draped in the usual sterile fashion.  A periumbilical incision was made to accommodate a handport off to the left side of the umbilicus.  Once the handport was in place, with posterior protection, a left abdominal wall 5-mm port was placed and CO2 gas insufflated to establish pneumoperitoneum.  A 12-mm port was placed through the right abdominal wall and a 5-mm port placed in the suprapubic area.  A 0-degree flexible tip scope was used to visualize the intraabdominal structures and attention was first turned to taking down the sigmoid colon from the abdominal wall.  This was performed with blunt and sharp dissection as well as Enseal device.  Care was taken not to injure the bowel.  With the bowel freed off the wall, progression was made up the left colic gutter to take down the splenic flexure which was fairly high compared to the level of the handport making it a little bit technically difficult and challenging to take down the splenic flexure, but this was accomplished with Enseal device, making sure there was no injury to the descending colon.  With the descending colon medialized and splenic flexure taken down, attention then turned to the pelvis and as I was working into the pelvis over the brim of the pelvis, there was the attachment to the bladder on the left side as noted under findings.  This was taken down bluntly with no spillage of any bowel contents appreciated.  The tract itself was fairly fibrotic.  The lighted stents have lights on and were easily identified within the retroperitoneum on both sides and kept protected throughout the procedure.  As the mesocolon down into the pelvis was transected near the colon since this was a benign case, a dilator was placed in the rectal vault to evaluate the level at which I will transect the colorectal junction just above the pelvic reflection.  This was accomplished after the mesocolon was transected at this level and an Echelon blue load 60-stapling device was fired across the colorectal junction at this point.  The mesocolon from this point proximal was then taken with Enseal device to maintain hemostasis up to above the pelvic brim, where the descending colon, sigmoid colon junction was, with no thickening or inflammatory changes at this point of resection.  An Echelon blue re-load was then fired across the proximal side of the sigmoid colon and the specimen was removed through the handport.  The descending colon was pulled up through the handport and a 29 circular stapling device was used. A pursestring device was fired below the staple line.  Staple line was cut out and bowel appeared healthy and viable at this point.  With the anvil in place, the pursestring was tied and this was dropped back down into the intraabdominal cavity.  With plenty of laxity to reach into the pelvis the circular stapling device was inserted through the rectum up into the rectum and the trocar was deployed through the wall of the rectum and attached to the anvil and as per manufacturer's instructions.  It was then tightened down and fired.  Good tissue donuts were obtained once the stapling device was removed and no tension was noted through the descending colon, no torsion of the mesocolon noted.  The proctoscope was inserted and air was insufflated with clamping of the descending colon to make sure there was no leaks from the anastomosis with a pool of saline around the anastomosis in the pelvis.  There was no leak appreciated and the rectal vault was desufflated, proctoscope removed.  The suction irrigator was used to remove the pool of saline and a 15 round Blake drain was placed through the left abdominal wall 5-mm port sites, secured to the abdominal wall with 2-0 nylon suture and placed in the pelvis anterior to the anastomosis.  The bladder was filled with sterile saline to make there was no leak from what appeared to be the fistular tract.  There was no leak intraabdominally, so I decompress the bladder.  The right abdominal 12-mm port and suprapubic port removed, pneumoperitoneum released, fascial defect at the handport was closed with 2 running 0-PDS double strand sutures, one from inferior side tied in the midline.  The subcutaneous tissue was irrigated with copious amounts of sterile saline and Polymyxin/Bacitracin mixture.  Hemostasis visualized.  Exparel was placed in the periumbilical area deep and superficial around the handport.  The skin edges were closed with skin staples at each of the port sites.  A Provena was placed over the midline.  All sponge and instrument counts were correct.  The patient was then awakened and taken to the Recovery Room in stable and satisfactory condition.


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