# Need Help for En Bloc Resection



## blarsen2 (Jun 19, 2014)

Transverse incision was made that was previously anesthetized and the peritoneal cavity was accessed with a 12 mm bladeless trocar and a 10 mm 0-degree scope under direct visualization.
This was a Covidien trocar. Once inside the peritoneal cavity, CO2
pneumoperitoneum was created. An additional 12 mm trocar was placed in left
lower quadrant through a separate stab incision under direct visualization after preanesthetized with local anesthetic and another 5 mm trocar was placed in the right upper quadrant in a vertical fashion through a separate stab incision under direct visualization after preanesthetized with local anesthetic. 

The patient was then placed into Trendelenburg position with the right side up
and I could identify the mass. There was definitely evidence of chronic
inflammation. The mass was densely adherent to the patient&apos;s abdominal sidewall and in fact the patient&apos;s mass was palpable once he was fully relaxed in the sleep through the abdominal wall. I also noted that a portion of the sigmoid colon appeared to be going into or being attached to this mass and I did not see any definite plane between the 2. I inspected the entire peritoneal cavity and found no evidence of metastatic disease. I inspected the liver and found no evidence of disease in the liver. I did briefly try taking down some of the attachments and adhesions to the lateral side wall and also some of the adhesions and attachments between the sigmoid colon in this mass including dividing 2 of the epiploic appendages that were involved with this mass. At this point in time, I felt that I was not going to be successful in completely dissecting this lesion out laparoscopically and in order to do a good cancer operation, I felt I needed to convert to open surgery. 

A generous vertical midline incision was created with a scalpel and then
ultimately entered into peritoneal cavity with Bovie electrocautery. The
patient&apos;s umbilical hernia, which was noted to be incarcerated with some omentum had been reduced while we were under laparoscopic surgery. I opened the midline incision through the hernia defect, so that I could repair as we completed the surgery. Once inside the peritoneal cavity, I was able to identify this mass. I think, the mass was only fixed by the sigmoid and the body side wall and I made the determination that I thought the mass was definitely resectable. I elected to do en bloc resection of the mass off the body sidewall and this was performed with Bovie electrocautery. During this process when I entered into the retroperitoneum, I identified the patient&apos;s right ureter and encircled with a vessel loop and used the vessel loop to keep it out of harm&apos;s way. The patient&apos;s gonadal vessels were also coming close to this inflammatory mass, but ultimately I was able to save the gonadal vessels and not divide them. 

Once I had freed up much of the retroperitoneal area, I then directed my
attention where the sigmoid colon was coming in. It seemed to be the midsigmoid colon was inflamed and densely adherent to this mass. I had already divided two of the appendages epiploica that were incorporated within this mass, but once I had opened, it was obvious that I was not going to be able to remove this mass without taking out portion of the sigmoid colon, at least not to the point that I would feel comfortable that there would be no damage to either the inflammatory mass or the sigmoid colon. Therefore, I made the decision to resect the portion of sigmoid colon that was densely adherent. I dissected approximately after identifying appropriate locations in the proximal sigmoid colon and transected with a GIA 80 mm staple load. Similarly, I dissected distally identifying the appropriate location distally and transected distally with the 80 mm GIA staple load. The mesentery between these 2 areas were then cauterized and divided utilizing the Harmonic Scalpel. 

Now that was taken care of, I elected to divide the ileocolonic artery.
Ileocolonic artery was identified, but it was not accessible at this point of
procedure to divide it, so then I continued my dissection of the right colon by
taking down the white line of Toldt all the way up to the hepatic flexure and
then taking down the hepatic flexure. This was all done with Bovie
electrocautery. I then dissected to the mid transverse colon. I identified the
middle colic vessels and transected the transverse colon proximal to the middle colic vessels. I also identified an appropriate location in the terminal ileum and then dissected out the terminal ileum and transected the terminal ileum with another firing of the GIA 80 mm staple load. The terminal ileum and right colonic mesentery was scored in a V-shaped pattern and making the division points of the terminal ileum and transverse colon. I could clearly palpate numerous lymph nodes in this area. We dissected the majority of the mesentry now with the Harmonic Scalpel, but towards the end at the ileocolonic artery, I placed a T-arm clamp on this area and then transected distally. The ileocolonic artery and vein were tied off with 0 Vicryl ties and suture ligated with 3-0 PDS. The specimen was now free and it was sent off the field for pathologic evaluation. 

Note, the bleeding at this point in time, I concluded the case. At the end of
the procedure, I did then open up the specimen on the back table. The findings are as follows,
1. The patient&apos;s appendix was very thickened and inflamed and is actually causing compression on the cecum near the ileocecal valve.
2. The patient does have a number of generous lymph nodes along the ileocolonic artery that were removed with the specimen.
3. Upon opening up into the appendix, there was inflammed mucosa, there was a large polyp and pus was obtained from the patient. The patient has
appendiceal lumen. This was all obviously done after the completion of the
case when the patient&apos;s belly was closed, so none of this put contaminated the wound. 

After I passed off the specimen and tied off the vessels. I then washed off the peritoneal cavity with slow irrigation fluid including. Hemostasis was noted to be adequate. I did palpate the patient&apos;s gallbladder, which was essentially unremarkable, gallbladder was somewhat distended, but did not appear to be acutely inflamed and I was not able to palpate the gallstones. Also, I did not inspect the patient&apos;s inguinal areas during the procedure. 

During my dissection of the right colon as I mentioned earlier, identified the
patient&apos;s right ureter and kept out of the harm&apos;s way. I also identified the patient&apos;s duodenum and kept out of the harm&apos;s way. 

I then performed a side-to-side functional end-to-end stapled GIA 80-mm blue
load. Anastomosis of the patient&apos;s terminal ileum and proximal transverse colon. After completing the anastomosis, inspection internally demonstrated hemostasis and the mucosa was healthy. End of the anastomosis stapled off with another firing of the 80 mm GIA blue load stapler. Inspection demonstrated a widely patent anastomosis. 

A 3-0 PDS crotch suture was placed. The staple lines appeared to be very
healthy, but I did elect to oversew the distal most staple lines with 3-0 PDS in
running Lembert fashion. The mesenteric defect was closed with 3-0 PDS in
running fashion. The abdomen was washed out with sterile irrigation fluid and
then I directed my attention to the patient&apos;s sigmoid colon. 

The sigmoid colon was reapproximated in a similar side-to-side functional end-to-end 80 mm stapled anastomosis. Proximal sigmoid and distal sigmoid were lined up and small openings were made into each one, so that I could pass a stapler. The stapler was easily passed and the sigmoid to sigmoid anastomosis was inspected internally, was noted be hemostatic and it was well perfused. The end of the sigmoid anastomosis was then closed off with another firing with the 80 mm blue load staple load. Reinspection demonstrated a widely patent anastomosis without evidence of leakage. At this point in time, the gloves were all changed. I should also mention that throughout the entire case, a wound protector was in position during this case and we had very little if no spillage whatsoever. 

I did reinforce the patient&apos;s sigmoid colon staple line with 3-0 PDS in running Lembert fashion for the distal staple line on the anastomosis. The other staple lines appeared to be very healthy. The mesentery was reapproximated with 3-0 PDS in running fashion. The abdomen was then irrigated out with sterile irrigation fluid. Hemostasis again was noted to be adequate. All foreign materials were removed. The 12 mm port sites were addressed internally. The fascia was reapproximated with 0 Vicryl from this area with #1 PDS in figure-of-eight fashion from on an internal fashion. 

I then positioned the omentum underneath the midline incision and reapproximated the fascia with #1 PDS in interrupted figure-of-eight fashion. This also effectively repaired the patient&apos;s umbilical hernia. Additional local anesthetic was infiltrated around this upper half of the wound for pain
management. The skin and subcutaneous tissue was irrigated out with sterile
irrigation fluid. 

The laparoscopic incisions were closed first with 4-0 Monocryl in interrupted
fashion. The skin and subcutaneous tissue of the midline incision was on hand
as I reapproximated the skin with 4-0 Monocryl in running subcuticular fashion. All wounds were then cleansed and dressed with Dermabond. The patient had tolerated the procedure well. There were no immediate complications. The patient was extubated and delivered to the recovery room in stable condition. 

Thanks for any help!


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