# Colostomy take-down;repair of iatrogenic enterotomies;adhesions



## bda23054 (Oct 29, 2012)

DATE OF OPERATION
10/08/12 

PREOPERATIVE DIAGNOSIS
Colostomy status post Hartmann procedure for diverticulitis.

POSTOPERATIVE DIAGNOSeS
1.  Colostomy status post Hartmann procedure for diverticulitis.
2.  Extensive intra-abdominal adhesions.
3.  Iatrogenic small bowel enterotomies.
4.  Accessory spleen.  

NAME OF OPERATION
Laparotomy with colostomy take-down and repair of iatrogenic enterotomies with adhesiolysis.

ANESTHESIA
General.

ESTIMATED BLOOD LOSS 
350 mL.

SPECIMENS
Small segment of small bowel sent.  

FINDINGS
This patient had a left abdominal wall colostomy that appeared viable with no obvious peristomal hernia.  The patient did have extensive intraabdominal adhesions to the anterior abdominal wall in the small bowel with initially getting into the abdomen there were actually 4 separate enterotomies made in loops of bowel.  Again, the bowel was essentially fused to the midline.  The patient has no evidence of acute infection within the intra-abdominal cavity.  The pelvis was clear of adhesions and Prolene stitch was placed at the staple line of the rectal stump still visible.  The anastomosis between the descending colon and rectal stump was without any air leak and with only minimal tension after taking down the splenic flexure.  He does have some postoperative changes, a ball of what appears to be splenic tissue and omentum in the right upper quadrant that was consistent with small accessory spleen since The patient does have a history of splenectomy.  The small bowel was not dilated.  The colon appeared to be viable.  The enterotomy site repairs did not have any evidence of strictures.  

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.  Anterior abdominal wall was then prepped and draped in the usual sterile fashion.  A Betadine soaked Ray-Tec was placed within the colostomy site and Ioban was placed down over the abdominal wall.  The patient was placed in low lithotomy position.  The Foley catheter was placed prior to the prep and drape.  The midline was opened with a 10 blade scalpel carrying dissection down to the fascia through the scar tissue with electrocautery.  As I get through the midline with what I thought was adequate posterior protection, I start opening the fascia with electrocautery and there was I note some bubbles indicative of enterotomy.  I then find this, put Allis clamps on it and attempt to open in a cephalad direction and develop another enterotomy.  At this point, with clamps on the enterotomies, one was fairly small area on distal ileum.  I oversew this with interrupted silk sutures without any leak noted or stricture at this site.  The other ileal enterotomy was a more circumferential injury.  I opted for a side-to-side anastomosis to repair this after initial closure of 0-silk to free up the small bowel fibrous adhesions.  With sharp dissection and blunt digital dissection, I carefully take down the rest of the intraabdominal adhesions from the ileocecal valve back to the ligament of Treitz was able to freed up and again, a side-to-side anastomosis was used to remove the 2 proximal areas of enterotomies taking out a small, about 15 cm loop of bowel between the 2 enterotomies.  The other enterotomy required a side-to-side stapling, at least 30 cm from this site, and i did not want to take out that much healthy bowel, so I made another side-to-side anastomosis to repair this enterotomy.  This was done with GIA-75 stapling device fired along both limbs after they were approximated with 3-0 silk serosal stitches and a TA-60 stapling device was fired across the enterotomy to close it.  This was oversewn with interrupted Lembert stitch 3-0 silk sutures.  This was done to maintain hemostasis.  The mesenteric defect the proximal repair was closed with a 2-0 Vicryl.  There was essentially no mesenteric repair at the distal repair since it was just placing the 2 limbs side-to-side and close the enterotomy.  Attention was then turned to the colostomy.  It was dissected down taking care not to lose the vascular supply to the descending colon.  Once it was able to be skeletonized adequately at the level of the fascia, a stapling device was fired across it and the adhesions in the left upper quadrant were taken down to get a little more slack on the descending limb of the colon.  Once I get adequate length into the pelvis, I place a pursestring device across the distal end of the colon and cut out the staple line, place the 29 mm anvil and use a pursestring device to secure the bowel up around it.  This dropped back down into the pelvis after Bookwalter self-retaining retractor was placed to keep the small bowel out of the pelvis and the stapling device was placed in the rectal vault and the perineum was pulled back off of the rectal stump after being incised with electrocautery, taking care not to injure the underlying rectal stump.  With the stapling device deployed through the rectal stump, it was attached to the descending colon limb and fired per manufacturer's instructions after there was no significant tension left on the descending limb.  The proctoscope was then inserted into the rectal stump and used to insufflate the anastomosis with air.  There was no leak appreciated with the anastomosis in a pool of saline.  The rectal vault and distal colon were decompressed.  Proctoscope removed and the small bowel was placed in its normal anatomical position within the intra-abdominal cavity.  Copious amounts of sterile saline were used to irrigate the left upper quadrant, left colic gutter, and right colic gutter until it returned clear.  The patient did have quite a bit of oozing with taking down adhesions but no active bleeding was appreciated at this point.  The abdominal wall was then closed in the midline with running double strand 0-PDS with interrupted figure-of-eight 0-PDS every 4-5 throws of the running continuous.  The continuous suture was tied in the midline and subcutaneous tissue was irrigated with a liter of sterile saline followed by 500 mL of Polymyxin/Bacitracin normal saline mixture and skin edges were closed with skin staples.  A blue towel was placed over this and attention was turned to the colostomy site.  Allis were used to elevate the colostomy site and was incised around the edges with electrocautery, kept elevated and dissection was carried down to the fascia.  The colostomy limb was removed in its entirety taking care not to injure any underlying structures since the midline was closed.  The fascial edges were cleaned up and the fascia was closed in a horizontal fashion with figure-of-eight 0-PDS sutures in interrupted fashion.  The subcutaneous tissue was irrigated with copious amounts of sterile saline and Betadine mixture followed by sterile saline Polymyxin/Bacitracin mixture that was left and skin edges were closed with skin staples.  Both sites were then covered with Silvercel followed by a silver sponge with no sponge touching the skin.  The occlusive dressing was applied over this at both sites and rather than drainage from one site to another, I placed a Y and 2 drainage lines to each site. Negative pressure was applied with no leak appreciated.  The patient was then taken out of low lithotomy position and placed in supine position and with Foley catheter left in place he was taken to the Recovery Room in stable and satisfactory condition.  All sponge and instrument counts were correct.  

DISPOSITION
Due to the enterotomies and length of the procedure I will continue the patient on postop antibiotics given the contamination and the fact that I was taking down colostomy.  The patient was a high risk of morbidity including infection after this procedure.  We will leave NG-tube in place at least until postop day 1 and await return of bowel function.  Please see the orders for complete detail.


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