ksb0211
Guest
So I don't want to miss anything on this case. Any additional insight would be greatly appreciated. I keep second guessing myself. Thanks.
POSTOPERATIVE DIAGNOSES
Colon carcinoma with pericolonic abscess, small bowel fistulization, involvement of the left tube and ovary. (153.2, 197.4, 198.6, 569.5, 569.81)
OPERATION PERFORMED (44204, 44213, 44120, 58661)
1. Laparoscopic hand-assisted left hemicolectomy with takedown of the splenic flexure.
2. Drainage of abdominal wall abscess.
3. Resection of fistulized small bowel.
4. Bilateral salpingo-oophorectomy.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room after attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. We made a 12 mm subxiphoid incision went into the abdominal cavity under direct vision, insufflated to 14 mmHg, placed a camera in and we could see that there was adhesed area, periumbilically and down to the left lower quadrant and we began to take this down. As we did there was a little bit of pus that came from it and we realized that our ability to do lot of this case laparoscopically was going to be mitigated by this large abscess, which was clearly involved with colon. We realized also that we were going to need a little bit of length so we took down the splenic flexure, we placed a port just above the xiphoid of the umbilicus and another one in the left upper quadrant and then using a Harmonic scalpel, we took down the white line of Toldt and then came across the lienocolic ligament, separating the colon from the vicinity of the spleen and reflecting it downward, we really got a really good mobilization of the colon and at this point we just went ahead and made an incision just from above the umbilicus to down below adjacent to this very large abscess. As it turned out, we opened could see that the small bowel was fistulized into this area densely adherent and not resectable and it looked like it was involved with a tumor. We could also see that the ureter on the left side was tented up into this mass, although not directly involved. The mass itself extended deep into the retroperitoneum and there was large bulky nodes palpable within the mesentery. We went ahead and fired a GIA both proximally and distally on the small bowel, leaving maybe about 8 cm of small bowel attached to this abscess cavity, then brought down the abscess cavity took cultures and once that was done, we could see that the colon with the lesion itself was quite bulky. We fired a GIA distally right across the distal sigmoid and then took down some of the mesentery, but we made sure that we identified the ureter. We also noted that this salpinx on the left side was involved in this mass. The ovary was adjacent to it, we took those both down, tied them off with 2-0 silks and left that all in block and then we dissected the mesentery up and then fired our staplers just above the mass may be about 5 cm margin both proximally and distally and then continued our dissection up there, taking down major bleeders with suture ligatures of 2-0 silk. Once we had taken down the mass we were able to hand it off and we taken out incontinuity, probably mid jejunum, the left tube and ovary as well as the mass itself with a lot of contained mesentery. We irrigated the site of the abscess cavity as well, placed clips around the abscess cavity site on the abdominal wall. These would be useful later we presume for postoperative irradiation of the abdominal wall which I think will be necessary. We then saw that we had enough length of our bowel to perform an end-to-side anastomosis. We freshened up both sides by removing an additional 5 cm both proximally and distally, introduced a 31 mm anvil into the distal colon and then went up with the stapler and made an end-to-end anastomosis from the descending colon to the rectosigmoid. At this point, we reinforced this anastomosis. There was no tension on it, but we reinforced it with 3-0 silk in a circumferential fashion, air tested it, placing a clamp distally there was no air leak at all and a reaction anastomosis looked quite good. We covered the anastomosis with some surrounding fat using 3-0 Vicryl, irrigated with antibiotic containing solution multiple times and then went ahead and aligned the small bowel along the antimesenteric border, introduced a 75 mm GIA with green staples and fired it making a 75 mm anastomosis. At this point, we had made our anastomosis, we closed the resultant rent with the TA-60 and then closed the rent and the mesentery with a running locking suture of 2-0 Vicryl. We irrigated once again and then turned our attention to the right ovary and salpinx taking those down again with 2-0 silk ties and completing the oophorectomy for fear of metastatic disease in this area. We then irrigated, placed a Jackson-Pratt in the pelvis, made sure we had a dry operative field, which we did, and then closed with a double stranded #1 PDS followed by irrigation followed by skin staples. The patient tolerated the procedure well.
POSTOPERATIVE DIAGNOSES
Colon carcinoma with pericolonic abscess, small bowel fistulization, involvement of the left tube and ovary. (153.2, 197.4, 198.6, 569.5, 569.81)
OPERATION PERFORMED (44204, 44213, 44120, 58661)
1. Laparoscopic hand-assisted left hemicolectomy with takedown of the splenic flexure.
2. Drainage of abdominal wall abscess.
3. Resection of fistulized small bowel.
4. Bilateral salpingo-oophorectomy.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room after attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. We made a 12 mm subxiphoid incision went into the abdominal cavity under direct vision, insufflated to 14 mmHg, placed a camera in and we could see that there was adhesed area, periumbilically and down to the left lower quadrant and we began to take this down. As we did there was a little bit of pus that came from it and we realized that our ability to do lot of this case laparoscopically was going to be mitigated by this large abscess, which was clearly involved with colon. We realized also that we were going to need a little bit of length so we took down the splenic flexure, we placed a port just above the xiphoid of the umbilicus and another one in the left upper quadrant and then using a Harmonic scalpel, we took down the white line of Toldt and then came across the lienocolic ligament, separating the colon from the vicinity of the spleen and reflecting it downward, we really got a really good mobilization of the colon and at this point we just went ahead and made an incision just from above the umbilicus to down below adjacent to this very large abscess. As it turned out, we opened could see that the small bowel was fistulized into this area densely adherent and not resectable and it looked like it was involved with a tumor. We could also see that the ureter on the left side was tented up into this mass, although not directly involved. The mass itself extended deep into the retroperitoneum and there was large bulky nodes palpable within the mesentery. We went ahead and fired a GIA both proximally and distally on the small bowel, leaving maybe about 8 cm of small bowel attached to this abscess cavity, then brought down the abscess cavity took cultures and once that was done, we could see that the colon with the lesion itself was quite bulky. We fired a GIA distally right across the distal sigmoid and then took down some of the mesentery, but we made sure that we identified the ureter. We also noted that this salpinx on the left side was involved in this mass. The ovary was adjacent to it, we took those both down, tied them off with 2-0 silks and left that all in block and then we dissected the mesentery up and then fired our staplers just above the mass may be about 5 cm margin both proximally and distally and then continued our dissection up there, taking down major bleeders with suture ligatures of 2-0 silk. Once we had taken down the mass we were able to hand it off and we taken out incontinuity, probably mid jejunum, the left tube and ovary as well as the mass itself with a lot of contained mesentery. We irrigated the site of the abscess cavity as well, placed clips around the abscess cavity site on the abdominal wall. These would be useful later we presume for postoperative irradiation of the abdominal wall which I think will be necessary. We then saw that we had enough length of our bowel to perform an end-to-side anastomosis. We freshened up both sides by removing an additional 5 cm both proximally and distally, introduced a 31 mm anvil into the distal colon and then went up with the stapler and made an end-to-end anastomosis from the descending colon to the rectosigmoid. At this point, we reinforced this anastomosis. There was no tension on it, but we reinforced it with 3-0 silk in a circumferential fashion, air tested it, placing a clamp distally there was no air leak at all and a reaction anastomosis looked quite good. We covered the anastomosis with some surrounding fat using 3-0 Vicryl, irrigated with antibiotic containing solution multiple times and then went ahead and aligned the small bowel along the antimesenteric border, introduced a 75 mm GIA with green staples and fired it making a 75 mm anastomosis. At this point, we had made our anastomosis, we closed the resultant rent with the TA-60 and then closed the rent and the mesentery with a running locking suture of 2-0 Vicryl. We irrigated once again and then turned our attention to the right ovary and salpinx taking those down again with 2-0 silk ties and completing the oophorectomy for fear of metastatic disease in this area. We then irrigated, placed a Jackson-Pratt in the pelvis, made sure we had a dry operative field, which we did, and then closed with a double stranded #1 PDS followed by irrigation followed by skin staples. The patient tolerated the procedure well.