ksb0211
Guest
When I first rec'd this op report, I coded it out without question. Then I started overthinking things again. Hoping for someone else's opinion on this one....
PREOPERATIVE DIAGNOSIS
History of left-sided colon cancer with anastomotic recurrence.
POSTOPERATIVE DIAGNOSIS
History of left-sided colon cancer with anastomotic recurrence.
PROCEDURE/OPERATION
Diagnostic laparoscopy with conversion to extended transverse colectomy.
SURGEON
XXXXXXXXXX
FIRST ASSISTANT
XXXXXXXXXX
ESTIMATED BLOOD LOSS
Scant
ANESTHESIA
General.
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room. After attainment of sufficient general anesthesia, he was pretreated with antibiotics and prepped and draped in the usual sterile fashion. A 5 mm supraumbilical incision was made and we entered the abdominal cavity with a Veress needle and insufflated to 14 mmHg. We placed a 5 mm port. We placed an additional 5 mm port up at the xiphoid. We used two previous excisions for both of these entries and once looking into the abdominal cavity there were no adhesions but what we could not find was the colon. The colon was buried by small bowel. It was adhesed from the prior surgery and looking at this laparoscopically we could see that there was just going to be no hope that we would be able to do this with a laparoscope, so what we did is we just opened a high abdominal incision which came down just below the umbilicus. We could see where the transverse colon was located and knowing from our previous op note we knew that the defect was probably up around the area of the splenic flexure. We opened the abdominal cavity and indeed found that the anastomosis was in the left upper quadrant. We could see the descending colon with the sigmoid coming up to meet it and then coming into the transverse colon with the mass located underneath a bit of omentum which was present in that left upper quadrant. We used the Harmonic scalpel, we divided the sigmoid and our plan was to try to do a curative resection on this mass and we are intent on taking a significant amount of mesentery, so we fired the GIA across the sigmoid and then reflected over, took down the mesentery of the sigmoid, and saw what had developed was kind of an internal hernia that was present back there through the mesentery. This previous case had been a laparoscopic colon resection. We then came across, freed up the area around the splenic flexure using the Harmonic scalpel and then identified the mesentery for the transverse colon, identified the middle colic arterial cascade, and then sort of divided it in half which gave us a lot of an apron coming over to the very distal area toward the splenic flexure where this anastomosis was present. Once we had resected all this mesentery we divided the transverse colon and then we were able to easily align the sigmoid with the transverse colon and use the GIA to make our anastomosis introducing a 75 mm green GIA in to the transverse colon, into the sigmoid, firing it, making our anastomosis. We had previously secured the antimesenteric border with 3-0 silks. Once that was done we closed the resultant rent with a TA-60 with green staples and then reapproximated the mesentery so as to have the bowel lay behind the small bowel and we sort of re-established the ligament of Treitz if you will, and then had the small bowel come up so that there would be no internal hernia. We irrigated with antibiotic containing solution, aspirated the fluid. There was very little blood loss in the course of the case. He tolerated the procedure quite well.
PREOPERATIVE DIAGNOSIS
History of left-sided colon cancer with anastomotic recurrence.
POSTOPERATIVE DIAGNOSIS
History of left-sided colon cancer with anastomotic recurrence.
PROCEDURE/OPERATION
Diagnostic laparoscopy with conversion to extended transverse colectomy.
SURGEON
XXXXXXXXXX
FIRST ASSISTANT
XXXXXXXXXX
ESTIMATED BLOOD LOSS
Scant
ANESTHESIA
General.
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room. After attainment of sufficient general anesthesia, he was pretreated with antibiotics and prepped and draped in the usual sterile fashion. A 5 mm supraumbilical incision was made and we entered the abdominal cavity with a Veress needle and insufflated to 14 mmHg. We placed a 5 mm port. We placed an additional 5 mm port up at the xiphoid. We used two previous excisions for both of these entries and once looking into the abdominal cavity there were no adhesions but what we could not find was the colon. The colon was buried by small bowel. It was adhesed from the prior surgery and looking at this laparoscopically we could see that there was just going to be no hope that we would be able to do this with a laparoscope, so what we did is we just opened a high abdominal incision which came down just below the umbilicus. We could see where the transverse colon was located and knowing from our previous op note we knew that the defect was probably up around the area of the splenic flexure. We opened the abdominal cavity and indeed found that the anastomosis was in the left upper quadrant. We could see the descending colon with the sigmoid coming up to meet it and then coming into the transverse colon with the mass located underneath a bit of omentum which was present in that left upper quadrant. We used the Harmonic scalpel, we divided the sigmoid and our plan was to try to do a curative resection on this mass and we are intent on taking a significant amount of mesentery, so we fired the GIA across the sigmoid and then reflected over, took down the mesentery of the sigmoid, and saw what had developed was kind of an internal hernia that was present back there through the mesentery. This previous case had been a laparoscopic colon resection. We then came across, freed up the area around the splenic flexure using the Harmonic scalpel and then identified the mesentery for the transverse colon, identified the middle colic arterial cascade, and then sort of divided it in half which gave us a lot of an apron coming over to the very distal area toward the splenic flexure where this anastomosis was present. Once we had resected all this mesentery we divided the transverse colon and then we were able to easily align the sigmoid with the transverse colon and use the GIA to make our anastomosis introducing a 75 mm green GIA in to the transverse colon, into the sigmoid, firing it, making our anastomosis. We had previously secured the antimesenteric border with 3-0 silks. Once that was done we closed the resultant rent with a TA-60 with green staples and then reapproximated the mesentery so as to have the bowel lay behind the small bowel and we sort of re-established the ligament of Treitz if you will, and then had the small bowel come up so that there would be no internal hernia. We irrigated with antibiotic containing solution, aspirated the fluid. There was very little blood loss in the course of the case. He tolerated the procedure quite well.
