# Hand-assisted laparoscopic right hemicolectomy with adhesiolysis.



## bda23054 (Nov 27, 2012)

could use some assistance on this one, please:

NAME OF OPERATION
Hand-assisted laparoscopic right hemicolectomy with adhesiolysis.

SPECIMEN
Right colon and a right upper quadrant peritoneal nodule sent fresh.

FINDINGS 
Upon establishment of pneumoperitoneum, the patient was noted to have a significant amount of omental adhesions in the midline lower abdomen consistent with a history of hysterectomy.  She also has a significant amount of adhesions to the right colic gutter and cecal area consistent with history of open appendectomy.  No dilated loops or transition points appreciated.  No obstruction noted.  The mass in the cecum was palpable 3 x 4 cm per preliminary pathology report.  No erosions or invasion into surrounding structures grossly obvious.  The anatomy was easily visualized and the right colic mesocolon was able to be taken down at its root.  The gallbladder was not inflamed and soft.  The liver was nodular, slightly sclerotic in appearance with no isolated lesions that were suspicious for metastatic disease.  The stomach and duodenum were nonpathologic.  The omentum was not firm or matted and not an indication of carcinomatosis.  The peritoneal nodule is white in the right upper quadrant without malignancy on preliminary report.  The anastomosis was made, was an side-to-side anastomosis, patent and without tension in the right upper quadrant.  

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.  A Foley catheter was placed.  The anterior abdominal wall was then prepped and draped in the usual sterile fashion.  A midline incision was made just above the umbilicus to accommodate a handport and once this was accomplished, with posterior digital protection a 5-mm port was placed in the left upper quadrant and CO2 gas insufflated to establish pneumoperitoneum.  0-degree flexible tip scope was then inserted and the above findings were appreciated.  The anterior abdominal wall adhesions were gently taken down bluntly and once this failed, a 12-mm port was placed in the right upper quadrant and an Enseal device was used to assist in taking down adhesions sharply and bluntly.  Once the hepatic flexure was exposed, the right colic gutter was incised and the adhesions over the cecum and ascending colon were taken down laterally to medialize the colon.  The distal ileum had a significant amount of adhesions tying it down over the brim of the pelvis and to get it pulled up to the handport to make an anastomosis, I take these adhesions down to medialize this and get some length on it.  The distal ileum and cecum were then pulled up through the handport along with the hepatic flexure, which was medialized and in the proximal transverse colon just passed the hepatic flexure.  There appeared to be a good blood supply and the colon was transected with a blue load 75-GIA stapling device.  The proximal transection was made with a blue re-load of the GIA stapling device about 20 cm from the ileocecal valve.  The mesentery was then taken down to its root, angled towards the right colic artery.  There were no isolated suspicious lymph nodes appreciated.  The mesentery was full though along its vascular supply, so I then reduce the specimen back into the colon and under laparoscopic guidance isolate the right colic vessels and once it was skeletonized, the right colic vessels were taken with white load echelon 60 stapling device laparoscopically.  Hemostasis visualized.  The specimen was then removed through the handport and sent to Pathology fresh.  Margins were adequate.  The transverse colon limb that appeared viable and the distal ileum limb are pulled up through the handport.  A side-to-side anastomosis was made with the 75-GIA stapling device, fired through enterotomy at either side of the antimesenteric border about 1 cm or 2 cm below the  couple of centimeters below the end of the staple lines.  The enterotomy was then closed with a 60-TA stapling device and oversewn interrupted fashion with Lembert stitches for hemostasis as needed.  The side-to-side anastomosis was patent, able to put 2 fingers through it. A 3-0 silk suture was placed in the crotch of the incision to take tension off of it.  The side-to-side anastomosis was then reduced down into the intraabdominal cavity in normal anatomic position in right upper quadrant.  There was a couple of loops of small bowel laying through the mesocolon defect.  These were taken back out, placed in the intraabdominal cavity.  The mesenteric defect was not closed.  The right colic gutter retroperitoneum was visualized.  No active bleeding was appreciated.  Sterile saline irrigation used up over the dome of the liver, returned clear, with no active bleeding appreciated.  The 12-mm port was removed with no intraabdominal bleeding.  The pneumoperitoneum was released.  Handport removed.  5-mm port removed.  The fascial defect at the midline incision was closed with a running 0-PDS suture double-strand, one from cephalad, one from caudad direction, tied in the midline.  Exparel 20 mL was placed circumferentially deep and superficially around the incision and copious amounts of sterile saline as well as Polymyxin/Bacitracin, normal saline mixture was used to irrigate subcutaneous tissue at each of the port sites.  The skin edges were reapproximated with skin stapler at each of the port sites including the midline handport.  The Foley catheter was left in place.  All sponge and instrument counts were correct.  The patient was awakened and taken to the Recovery Room in stable and satisfactory condition.


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## syllingk (Nov 28, 2012)

Looks pretty straight up.
44204


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## wcarmignani (Nov 29, 2012)

From the note it appears they transected the terminal ileum and the colon and performed an anastsomosis which would be 44205


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## georgie1414 (Oct 23, 2013)

*Could some one help me with this one*

OPERATIVE/PROCEDURE REPORT


DATE OF OPERATION/PROCEDURE:  10/14/2013




PREOPERATIVE DIAGNOSES:
Colon cancer of the cecum.  
Adhesions.


POSTOPERATIVE DIAGNOSES:
Colon cancer of the cecum.
Massive adhesions.


PROCEDURE:
Right colon resection.
Extensive adhesiolysis.



ANESTHESIA:
General local.


INDICATIONS:
The patient is a 71-year-old male who comes in with cecal cancer.  He is admitted for a right colon resection.  He has had a major laparotomy in the past and has adhesions from the laparotomy.  We discussed proceeding with right colon resection and adhesiolysis.  The risks and benefits were explained in detail up to and even including death from the procedure afterwards.  With the risks and benefits in mind, he and his family want to proceed at this time.


TECHNIQUE:
The patient was draped and prepped in normal sterile fashion and placed in the supine position.  Incision was made partially through the old incision.  Dissection was carried out down the abdominal cavity.  He had massive adhesions which we had to take down.  Once we took all the adhesions down, we dissected out the right colon.  We dissected along the white line of Toldt.  We dissected out the right colon all the way to the mid  transverse colon.  We stapled off the distal ileum.  We took the colon, appendix, and ileum altogether.  The mesentery of the colon was taken all the way close to the root of the mesentery as possible.  This was ligated with either clips or ties.  The distal end of the resection was stapled with the GIA stapler.  This was at the mid to distal transverse colon area.  Again, the entire specimen was removed in total without any spillage.  We anastomosed the small bowel to the transverse colon with a GIA and TX staplers.  Crotch stitches were placed.  We then closed the mesentery with 3-0 Vicryl.  We irrigated and checked for any bleeding.  We made sure the bowels were in anatomic position.  We made sure the NG was in good position.  There was no bleeding.  We then closed the fascia with 0 looped PDS.  There was some extraosseous bone growth which we removed with the bone remover.  We did not want this to cut the suture.  There was also a small hernia in the fascia from the previous surgery which we closed during the closure.  The subcu was irrigated and the skin was closed with staples.  All lap, sponge, and instrument counts were correct x2.


ESTIMATED BLOOD LOSS:
Less than 5 mL.


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