# Hand-assisted laparoscopic sigmoid resection



## sara0014 (Sep 18, 2013)

*I came up with 44204 but just wanting to make sure that is the only CPT I am picking up. He states exploration, just not not sure if I am to pick that up or not. FYI, I am a new general surgery so always second guessing myself.*

PREOPERATIVE DIAGNOSIS: Sigmoid diverticular disease versus sigmoid carcinoma. 

POSTOPERATIVE DIAGNOSIS:  Apparent sigmoid diverticular disease, no evidence of carcinoma.  

PROCEDURE:  Hand-assisted laparoscopic sigmoid resection. 

COMPLICATIONS:  None. 

HISTORY OF GROSS FINDINGS:  This 46 year-old male was seen in the last few weeks for a colonoscopy.  It had been a year since his prior colon exam.  During his second colonoscopy intervention, we found severe sigmoid disease, which was not amenable to colonoscopy.  He was sent for a barium enema. Barium would not fill retrograde into his colon due to severely tortuous diseased sigmoid.  He was then referred for a CT scan which showed significant deformity of his sigmoid with concern about a neoplasm.  Surgery was recommended and today performed.  A mass of diseased tissue was noted in the left lower quadrant.  I couldn't make the diagnosis, so laparoscopically we had to do the sigmoid resection to be able to even open the tissue. During the procedure we were able to excise the sigmoid and open the specimen intraoperatively and examine it.  It appeared to be consistent with chronic severe diverticular disease.  The end-to- end anastomosis went rather well, and there was no evidence of other intra-abdominal disease.  There was no abscess encountered.  Previously laparoscopic hiatal hernia repair was examined and there was no apparent complication from this.  

PROCEDURE:  The patient was taken to the operating room and placed under the general anesthetic in the dorsal lithotomy position and was sterilely prepped and draped.  His rectum was irrigated with saline and he had a Foley catheter in place.  Using a scalpel a left lower quadrant 8 cm incision was created.  Subcutaneous tissue was divided down to the rectus sheath which was open laterally near the linea semilunaris.  The anterior rectus sheath was retracted medially.  The rectus muscle was retracted medially.  There was no muscular division at all during this case.  I opened up the posterior rectus sheath and entered the abdomen.  I placed a gel port, placed my left hand in and we proceeded with two additional ports, one measuring 11 mm just above the umbilicus and one measuring 12 mm to the right lower quadrant.  The abdomen was insufflated to a pressure of 15 mm CO2.  We were then able to do a complete* exploration *which was otherwise unremarkable, with the exception of the severe disease in the left lower quadrant, which was very adherent to the lateral pelvic side wall, relatively close to where the ureter would be.  Great care was taken to avoid ureteral injury.  Using a LigaSure device I was able to dissect most of the disease off the abdominal wall and lateral pelvis, taking care not to injure a ureter.  I was ultimately able to visualize the left ureter and it was kept from harm.  Transection of the proximal portion of the surgery was carried out, first with a 60 mm GIA, which was fired twice.  LigaSure was used for mesenteric division and a window was created distally above the rectum, where a 60 mm stapler was fired. Completion of the mesenteric division was relatively uncomplicated.  During the procedure there was one vessel encountered which was only partially cauterized by the LigaSure and had to be managed with repeated LigaSure application, until we had good hemostasis.  Once complete mesenteric division was carried out, I was able to pull the sigmoid resection out through the 8 cm incision, though I must admit it was quite difficult, as the specimen was greater than 8 cm in diameter.  With some care we were able to maneuver it out. We then examined it on the back table and determined this was a benign condition, consistent with diverticulitis.  Gloves were changed and we resumed the operation.  Delivering the proximal sigmoid colon into the field, we had to resect the proximal sigmoid to get a nice perpendicular division point at the descending colon sigmoid junction.  We accomplished this with a 60 mm GIA.  I defatted the staple end, applied a purse-string device and fired it.  We defatted prior to that.  We cut away the staple line, after that we removed the purse stringer, triangulated the bowel with Allis clamps, placed EEA sizers.  We were able to get a 29 mm sizer in.  We called for a 28 mm EEA, placed the anvil in, and closed the purse string, defatted, placed the anvil back into the abdomen, re-established pneumoperitoneum with a gel port in place.  Dr. assistant then passed the EEA, under my guidance, into the rectum, to the stump of distal sigmoid.  We delivered the spike right through the staple line, the center, connected the anvil and closed the EEA and fired it.  The EEA was removed carefully and two donuts of complete tissue were examined.  We then established a hydroperitoneum with saline and insufflated with a lighted proctoscope into the distal anastomosis.  Allowing for pressure build up, there was no air leak. We did this both with saline in the pelvis and then evacuated the saline and then checked direct visualization.  There was no problem with the anastomosis.  There was no tension.  Sponge, instrument and needle counts were called and found to be correct.  The abdomen was free of any bleeding.  We exsufflated, placed the patient supine, closed the peritoneum of the large incision with 0 Vicryl suture, closed the rectus sheath with 0 Vicryl suture.  Subcutaneous fat with 3-0 Vicryl suture.  The skin was closed at all sites with subcuticular Vicryl suture.  Skin was cleansed and dried and sterile dressings were applied.  The patient was sent to recovery extubated and in stable condition.  He tolerated the procedure well.


----------

