ksb0211
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Drainage of retro splenic flexure abscess, diverting colostomy & partial omentectomy
Hello. I'm hoping for a second opinion (or 3rd LOL) on this one. I don't want to miss anything. Thanks a lot!
PREOPERATIVE DIAGNOSIS
Sepsis, rule out acute abdomen.
POSTOPERATIVE DIAGNOSES
1. Acute abdomen with retro splenic flexure abscess.
2. Portal hypertension.
3. Infected ascites.
OPERATION PERFORMED
Diagnostic laparoscopy with conversion to exploratory laparotomy. Drainage of retro splenic flexure abscess and performance of diverting colostomy and partial omentectomy.
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 5 mm supraumbilical incision. We entered the abdominal cavity with a Veress needle. We insufflated 14 mmHg, placed a 5 mm port, got in and saw that we were beneath the omentum which was adhesed above, actually it was kind of a lucky break because the omentum was out of the way and we could actually see the small bowel which did not look ischemic it all. Looked down toward the pelvis and we could see this kind of yellowish, turbid fluid which we aspirated and remitted for Gram stain, which revealed many WBCs but no organisms were noted, aspirated that fluid and then we decided we really want to have a little bit better look and so we went up to the left upper quadrant. We could not get the omentum down, went up to the left upper quadrant, again went in with a 5 mm port and as we carried out our exploration we went to the top of the omentum which looked unremarkable and we were getting ready to leave, looked down the left gutter, could see where the colon was, did not really see much there, aspirated more of the ascites fluid and we were ready to scribe this all to primary bacterial peritonitis and we looked up in the left upper quadrant and there was some purulent material present there which looked suspicious. At this point, we felt this might be a perforated ulcer, looked back over toward the right upper quadrant but really could not see very much because of the adhesions from previous open cholecystectomy. We also noted the presence of very engorged omental vasculature consistent with her portal hypertension, a markedly cirrhotic liver. We opened the patient on the midline, immediately got into a significant amount of bleeding from the preperitoneal area. Used the Harmonic Scalpel to control that. As we took down omentum, it bled a lot and we used the Harmonic Scalpel on it, but as we lysed adhesions we were just getting tearing it into this omental vessels causing quite a significant amount of bleeding, controlled this with the Harmonic Scalpel. Elected to discontinue trying to go up into the right upper quadrant but we felt around back there and looking at our glove we did not find any purulent material. It did not look particularly bad and with our being able to put traction on the area we could see that they really did look like there was anything going on in that area; went down toward the pelvis thinking maybe this diverticular disease. We found some purulent material in the pelvis. We carefully took down the omentum around the umbilicus, which it was adhesed at the umbilicus and down onto the midline and again it bled like crazy requiring resection of the omentum to get the bleeding under control. We took off about a 3rd of the omentum. Then looked down in the lower quadrant of the abdomen, aspirated the fluid, did not see anything of great consequence down there, irrigated and in the colon there was some inspissated stool, but the colon did look abnormal. Came back up in the left upper quadrant to further explore this area where we saw the purulent material and low and behold we found some purulent material covering the top of the spleen and laterally. As we dissected down there we could see that the splenic flexure of the colon was in that area as we went behind there we got into an abscess cavity which drained frank pus. At this plan to consider exactly what we were dealing. It was not apparently diverticular disease but there was clearly an abscess and the abscess was right behind the colon in the area of the splenic flexure so we decided would tried to take this down. This area was for hypervascular and because of the portal hypertension, once again we got into a lot of bleeding and eventually we decided that rather than try to take down the splenic flexure, which was really dangerous we would just divert the patient and be done with it given her overall prognosis is quite bad, went ahead and fired a stapler just to the proximal portion of the transverse colon, mobilized the omentum, made a rent in the right upper quadrant, brought the colostomy out and secured the colostomy to the abdominal wall with 2-0 silks. Once that was done, we tagged the distal end of the colon, this is mid transverse colon, with two 2-0 Prolene to allow us to easily find should anyone ever desire to go back into his abdomen which I doubt would recur, but nevertheless placed a drain into the abscess cavity laterally, irrigated the abdominal cavity with about 3 L of fluid, aspirated all fluid, carefully reordered the small bowel back within the abdominal cavity, covered it with omentum and then closed the wound with double stranded #1 PDS followed by 3-0 Vicryl followed by irrigation followed by skin staples. We then covered the wound and matured the colostomy on the table. The patient actually tolerated the procedure well. My overall feeling is that she is not going to do well but I think under the circumstances we did just sort of salvaged what we could of the situation.
Hello. I'm hoping for a second opinion (or 3rd LOL) on this one. I don't want to miss anything. Thanks a lot!
PREOPERATIVE DIAGNOSIS
Sepsis, rule out acute abdomen.
POSTOPERATIVE DIAGNOSES
1. Acute abdomen with retro splenic flexure abscess.
2. Portal hypertension.
3. Infected ascites.
OPERATION PERFORMED
Diagnostic laparoscopy with conversion to exploratory laparotomy. Drainage of retro splenic flexure abscess and performance of diverting colostomy and partial omentectomy.
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 5 mm supraumbilical incision. We entered the abdominal cavity with a Veress needle. We insufflated 14 mmHg, placed a 5 mm port, got in and saw that we were beneath the omentum which was adhesed above, actually it was kind of a lucky break because the omentum was out of the way and we could actually see the small bowel which did not look ischemic it all. Looked down toward the pelvis and we could see this kind of yellowish, turbid fluid which we aspirated and remitted for Gram stain, which revealed many WBCs but no organisms were noted, aspirated that fluid and then we decided we really want to have a little bit better look and so we went up to the left upper quadrant. We could not get the omentum down, went up to the left upper quadrant, again went in with a 5 mm port and as we carried out our exploration we went to the top of the omentum which looked unremarkable and we were getting ready to leave, looked down the left gutter, could see where the colon was, did not really see much there, aspirated more of the ascites fluid and we were ready to scribe this all to primary bacterial peritonitis and we looked up in the left upper quadrant and there was some purulent material present there which looked suspicious. At this point, we felt this might be a perforated ulcer, looked back over toward the right upper quadrant but really could not see very much because of the adhesions from previous open cholecystectomy. We also noted the presence of very engorged omental vasculature consistent with her portal hypertension, a markedly cirrhotic liver. We opened the patient on the midline, immediately got into a significant amount of bleeding from the preperitoneal area. Used the Harmonic Scalpel to control that. As we took down omentum, it bled a lot and we used the Harmonic Scalpel on it, but as we lysed adhesions we were just getting tearing it into this omental vessels causing quite a significant amount of bleeding, controlled this with the Harmonic Scalpel. Elected to discontinue trying to go up into the right upper quadrant but we felt around back there and looking at our glove we did not find any purulent material. It did not look particularly bad and with our being able to put traction on the area we could see that they really did look like there was anything going on in that area; went down toward the pelvis thinking maybe this diverticular disease. We found some purulent material in the pelvis. We carefully took down the omentum around the umbilicus, which it was adhesed at the umbilicus and down onto the midline and again it bled like crazy requiring resection of the omentum to get the bleeding under control. We took off about a 3rd of the omentum. Then looked down in the lower quadrant of the abdomen, aspirated the fluid, did not see anything of great consequence down there, irrigated and in the colon there was some inspissated stool, but the colon did look abnormal. Came back up in the left upper quadrant to further explore this area where we saw the purulent material and low and behold we found some purulent material covering the top of the spleen and laterally. As we dissected down there we could see that the splenic flexure of the colon was in that area as we went behind there we got into an abscess cavity which drained frank pus. At this plan to consider exactly what we were dealing. It was not apparently diverticular disease but there was clearly an abscess and the abscess was right behind the colon in the area of the splenic flexure so we decided would tried to take this down. This area was for hypervascular and because of the portal hypertension, once again we got into a lot of bleeding and eventually we decided that rather than try to take down the splenic flexure, which was really dangerous we would just divert the patient and be done with it given her overall prognosis is quite bad, went ahead and fired a stapler just to the proximal portion of the transverse colon, mobilized the omentum, made a rent in the right upper quadrant, brought the colostomy out and secured the colostomy to the abdominal wall with 2-0 silks. Once that was done, we tagged the distal end of the colon, this is mid transverse colon, with two 2-0 Prolene to allow us to easily find should anyone ever desire to go back into his abdomen which I doubt would recur, but nevertheless placed a drain into the abscess cavity laterally, irrigated the abdominal cavity with about 3 L of fluid, aspirated all fluid, carefully reordered the small bowel back within the abdominal cavity, covered it with omentum and then closed the wound with double stranded #1 PDS followed by 3-0 Vicryl followed by irrigation followed by skin staples. We then covered the wound and matured the colostomy on the table. The patient actually tolerated the procedure well. My overall feeling is that she is not going to do well but I think under the circumstances we did just sort of salvaged what we could of the situation.