ksb0211
Guest
Colectomy assistance please (lap left hemicolectomy & open mid transverse colectomy)
Hello, my fellow coders. This one has me stumped. Any insight is appreciated. As you can see, it's not the "usual" hemicolectomy. This is the weirdness I got......
Procedure:
....I made a 5 mm supraumbilical incision into the abdominal cavity with a Veress needle. We insufflated to 14 mmHg, placed a 5 mm port, placed an additional 5 mm port near the xiphoid and one in the left lower quadrant. Using initially a Harmonic Scalpel, we took down the white line of Toldt. We saw that there was some purulent material in the pelvis that was not a lot, just a little bit, and we went ahead and we could feel that the mass was covered with some omentum. We really did not see up that we could tell it was right more or less at the true pelvis consistent with the gastroenterologist's report. We mobilized the colon along the white line of Toldt and then came up around the splenic flexure, mobilized it up there. We lifted up the omentum, and we had hoped that the second lesion was in the area of about the splenic flexure, so we could do this as an extended left hemicolectomy, but in actuality the lesion was really dead center just maybe a little bit to the right of the falciform ligament, so the idea of doing an extended left hemicolectomy having being the right colon down to the pelvis on this rather big guy did not seem to make a lot of sense, so we decided just to do it in 2 separate areas, which again therewere advantages and disadvantages at a concept, so we did that, so we mobilized the colon.
We went ahead and went in opn and developed our exposure using a bookwalter retractor, took down a little bit more the pelvic adhesions that were down there and a little bit of adhesions. It turned out that the surface of this lesion was glossy, maybe slightly suppurative, but not obviously infected, and there was no abscess. I went ahead and fired a GIA proximally and then reflected the colon to the right, and I identified the ureter on the left side. I then took down the mesocolon between clamps, the cavity was down into the true pelvis. I then resected the colon using a contour device just above the peritoneal reflection. At this point, we had plenty of room to make our anastomosis with the mobilization that we had carried out, adn we just left that in place, irrigated, placed the antibiotic-containing solution into the area and then went up to the transverse colon, realized that this would really be hard to do laparoscopically and what we did because we knew precisely it was. We had already mobilized the colon, We just made an incision on the midline, and we were very easily able to bring up a great length of transverse colon, and we took it down in a kind of a wedge-shaped fashion. This lesion was probably 1.5 cm in diameter. It was very small compared to the one that we hadremoved in the sigmoid colon. I could feel it on the mesenteric border of the transverse colon adjacent to the tattoo mark. We took down the mesocolon. We took down the middle colic vessels to a great extent and that left us with 2 limbs of transverse colon. We placed the side to side again with our mobilization. This was relatively easy to do, and we introduced a GIA. We had severed both of these portions of the colon with the GIA, and we had switched over to a Caiman device for sealing the mesentery, but the large vessels were all tied off with 2-0 silks in such a fashion as to make sure we had a very hemostatic field. Once that was done, we opposed both side to side of the colon, introduced a 75 mm GIA with 4.8 mm staples, fired it, making our anastomosis, closing the resultant rent with a TA-60 and then we covered that anastomosis using 3-0 Vicryl, and we used omentum to cover the entirety of the anastomosis that contained and make sure that there were no leaks; however, we did not that the inferior mesenteric artery was left intact, and then we felt that we had plenty of blood flow both to the sigmoid and to the transverse colon. We went down at this point and turned our attention to making the anastomosis. At the sigmoid colon, we placed a pursestring device across the proximal end of the colon, fired it, sized out the colon to a 31 mm. [The assistant surgeon] then went down below and sized out the rectum to an easy 31 mm, and we then placed an anvil into the sigmoid, tied down the sutures from the pursestring device, took some surrounding fat off the colon, then connected the anvil to the device as we extruded that device right through the staple line, having perfect placement on the colon, tightening it down, firing it, making a 31 mm anastomosis. We then removed the CEA Plus, cross clamped the colon up to the descending colon area and then insufflated through a sigmoidoscope with antibiotic fluid being placed in the pelvis, and there was no leak at all with good tension with the sigmoid insufflation. I expressed all the air that was inside, made sure we had no tension on the anastomosis, we did not. We put some reinforcing sutures into that anastomosis just to make sure it was okay and closed with 3-0 silks, going more ofcircumferentially, we did not do the back so much, but we got probably 270 degrees without any difficulty and then at that point, we place a Jackson-Pratt throught the laparoscopic port site in the left lower quadrant, secured that with a 3-0 nylon, irrigated copiously in all fields and then closed with double stranded #1 PDS at the sigmoid area and then a #1 PDS up in th xiphoid. There were 2 incisions made by the way. When we switched away from the lapaoroscopic technique, we did make an incision in the lower abdomen. We then irrigated and placed Ancef powder into the wound, closed with 3-0 Vicryl and then skin staples. Patient tolerated the procedure well.
Hello, my fellow coders. This one has me stumped. Any insight is appreciated. As you can see, it's not the "usual" hemicolectomy. This is the weirdness I got......
Procedure:
....I made a 5 mm supraumbilical incision into the abdominal cavity with a Veress needle. We insufflated to 14 mmHg, placed a 5 mm port, placed an additional 5 mm port near the xiphoid and one in the left lower quadrant. Using initially a Harmonic Scalpel, we took down the white line of Toldt. We saw that there was some purulent material in the pelvis that was not a lot, just a little bit, and we went ahead and we could feel that the mass was covered with some omentum. We really did not see up that we could tell it was right more or less at the true pelvis consistent with the gastroenterologist's report. We mobilized the colon along the white line of Toldt and then came up around the splenic flexure, mobilized it up there. We lifted up the omentum, and we had hoped that the second lesion was in the area of about the splenic flexure, so we could do this as an extended left hemicolectomy, but in actuality the lesion was really dead center just maybe a little bit to the right of the falciform ligament, so the idea of doing an extended left hemicolectomy having being the right colon down to the pelvis on this rather big guy did not seem to make a lot of sense, so we decided just to do it in 2 separate areas, which again therewere advantages and disadvantages at a concept, so we did that, so we mobilized the colon.
We went ahead and went in opn and developed our exposure using a bookwalter retractor, took down a little bit more the pelvic adhesions that were down there and a little bit of adhesions. It turned out that the surface of this lesion was glossy, maybe slightly suppurative, but not obviously infected, and there was no abscess. I went ahead and fired a GIA proximally and then reflected the colon to the right, and I identified the ureter on the left side. I then took down the mesocolon between clamps, the cavity was down into the true pelvis. I then resected the colon using a contour device just above the peritoneal reflection. At this point, we had plenty of room to make our anastomosis with the mobilization that we had carried out, adn we just left that in place, irrigated, placed the antibiotic-containing solution into the area and then went up to the transverse colon, realized that this would really be hard to do laparoscopically and what we did because we knew precisely it was. We had already mobilized the colon, We just made an incision on the midline, and we were very easily able to bring up a great length of transverse colon, and we took it down in a kind of a wedge-shaped fashion. This lesion was probably 1.5 cm in diameter. It was very small compared to the one that we hadremoved in the sigmoid colon. I could feel it on the mesenteric border of the transverse colon adjacent to the tattoo mark. We took down the mesocolon. We took down the middle colic vessels to a great extent and that left us with 2 limbs of transverse colon. We placed the side to side again with our mobilization. This was relatively easy to do, and we introduced a GIA. We had severed both of these portions of the colon with the GIA, and we had switched over to a Caiman device for sealing the mesentery, but the large vessels were all tied off with 2-0 silks in such a fashion as to make sure we had a very hemostatic field. Once that was done, we opposed both side to side of the colon, introduced a 75 mm GIA with 4.8 mm staples, fired it, making our anastomosis, closing the resultant rent with a TA-60 and then we covered that anastomosis using 3-0 Vicryl, and we used omentum to cover the entirety of the anastomosis that contained and make sure that there were no leaks; however, we did not that the inferior mesenteric artery was left intact, and then we felt that we had plenty of blood flow both to the sigmoid and to the transverse colon. We went down at this point and turned our attention to making the anastomosis. At the sigmoid colon, we placed a pursestring device across the proximal end of the colon, fired it, sized out the colon to a 31 mm. [The assistant surgeon] then went down below and sized out the rectum to an easy 31 mm, and we then placed an anvil into the sigmoid, tied down the sutures from the pursestring device, took some surrounding fat off the colon, then connected the anvil to the device as we extruded that device right through the staple line, having perfect placement on the colon, tightening it down, firing it, making a 31 mm anastomosis. We then removed the CEA Plus, cross clamped the colon up to the descending colon area and then insufflated through a sigmoidoscope with antibiotic fluid being placed in the pelvis, and there was no leak at all with good tension with the sigmoid insufflation. I expressed all the air that was inside, made sure we had no tension on the anastomosis, we did not. We put some reinforcing sutures into that anastomosis just to make sure it was okay and closed with 3-0 silks, going more ofcircumferentially, we did not do the back so much, but we got probably 270 degrees without any difficulty and then at that point, we place a Jackson-Pratt throught the laparoscopic port site in the left lower quadrant, secured that with a 3-0 nylon, irrigated copiously in all fields and then closed with double stranded #1 PDS at the sigmoid area and then a #1 PDS up in th xiphoid. There were 2 incisions made by the way. When we switched away from the lapaoroscopic technique, we did make an incision in the lower abdomen. We then irrigated and placed Ancef powder into the wound, closed with 3-0 Vicryl and then skin staples. Patient tolerated the procedure well.