philnamba
Contributor
I am new to coding of the intestines...my provider did the following...any guidence would be GREATLY appreciated!!
Under adequate general anesthetic, the abdomen was prepped and draped in the usual sterile fashion. The wound VAC device was removed prior to wet prep. The small fascial closure was opened by incising the closure suture. The proximally 3 L of enteric contents were evacuated throughout the abdomen. As seen previously, the abdomen was basically frozen by very severe adhesions and edematous bowel. Sharp and blunt dissection was used to break up adhesions enough to identify bowel. This was an extremely difficult dissection due to the above-mentioned factors. The incision was extended slightly superiorly and inferiorly and the previously placed Strattice removed. Eventually, the area of the anastomosis in the left lateral abdomen was identified as the leakage point. The staple line had entirely broken down along one edge of the anastomosis. With considerable difficulty, this area of the bowel was mobilized up to the midabdomen. Identification of bowel, vessels or mesentery was nearly impossible. Eventually a very dilated segment of bowel proximal to the anastomotic breakdown was dissected out and a presumed distal, decompressed segment of bowel was also identified. The mesenteric border was taken down with clamps and tied with 3-0 Vicryl and the bowel divided distally with a GIA stapler. The approximate diameter of the dilated bowel was 4 cm with a very edematous mesentery and wall. No the area of bowel appear to be at all adequate for reanastomosis, particularly considering the breakdown from the previous surgery a few days ago. It was therefore elected to attempt an ostomy. Unfortunately with the patient's thick abdominal wall and extremely edematous and shortened small bowel, the ostomy was basically an enterocutaneous fistula. We were able to bring the bowel wall to the anterior fascia of the rectus, but no further poor the skin. A circular incision was made in the fatty tissue excised with electrocautery to the right of midline to allow this fistula creation. This was sutured circumferentially to the anterior fascia with interrupted 3-0 Vicryl. This is obviously a very suboptimal ostomy, but further mobilization was impossible. There was a small area of small bowel leakage more superior in the abdomen which was oversewn with 4-0 PDS. This did not appear to be at all mobilized both and is presumed do to the very difficult dissection. The smaller segment of jejunum stapled presumably distal to the anastomosis was taken to the left side of the abdomen as much as possible. A 14 French T tube was tunneled through a separate stab incision into the abdomen and sewn into this segment of presumed jejunum with a 4-0 PDS. This segment of bowel was sutured to the anterior abdominal wall with interrupted 3-0 silk. The abdomen was then irrigated and evacuated. #2 nylon sutures were used as retention sutures through the fascia. The previous hernia defect was closed laterally and the transverse fashion with number one PDS. The midline fascia was then reapproximated with running looped 0 PDS. Retention sutures were tied over bridges. The abdomen did not appear to be overly tight, and unfortunately another segment of Strattice did not appear to be a feasible area of closure. We were also reluctant to leave an open abdomen because of difficulty with the ostomies. Skin and subcutaneous tissues were packed with Betadine soaked Kerlix gauze and outer dressings applied. Patient was taken to the intensive care unit intubated.
Under adequate general anesthetic, the abdomen was prepped and draped in the usual sterile fashion. The wound VAC device was removed prior to wet prep. The small fascial closure was opened by incising the closure suture. The proximally 3 L of enteric contents were evacuated throughout the abdomen. As seen previously, the abdomen was basically frozen by very severe adhesions and edematous bowel. Sharp and blunt dissection was used to break up adhesions enough to identify bowel. This was an extremely difficult dissection due to the above-mentioned factors. The incision was extended slightly superiorly and inferiorly and the previously placed Strattice removed. Eventually, the area of the anastomosis in the left lateral abdomen was identified as the leakage point. The staple line had entirely broken down along one edge of the anastomosis. With considerable difficulty, this area of the bowel was mobilized up to the midabdomen. Identification of bowel, vessels or mesentery was nearly impossible. Eventually a very dilated segment of bowel proximal to the anastomotic breakdown was dissected out and a presumed distal, decompressed segment of bowel was also identified. The mesenteric border was taken down with clamps and tied with 3-0 Vicryl and the bowel divided distally with a GIA stapler. The approximate diameter of the dilated bowel was 4 cm with a very edematous mesentery and wall. No the area of bowel appear to be at all adequate for reanastomosis, particularly considering the breakdown from the previous surgery a few days ago. It was therefore elected to attempt an ostomy. Unfortunately with the patient's thick abdominal wall and extremely edematous and shortened small bowel, the ostomy was basically an enterocutaneous fistula. We were able to bring the bowel wall to the anterior fascia of the rectus, but no further poor the skin. A circular incision was made in the fatty tissue excised with electrocautery to the right of midline to allow this fistula creation. This was sutured circumferentially to the anterior fascia with interrupted 3-0 Vicryl. This is obviously a very suboptimal ostomy, but further mobilization was impossible. There was a small area of small bowel leakage more superior in the abdomen which was oversewn with 4-0 PDS. This did not appear to be at all mobilized both and is presumed do to the very difficult dissection. The smaller segment of jejunum stapled presumably distal to the anastomosis was taken to the left side of the abdomen as much as possible. A 14 French T tube was tunneled through a separate stab incision into the abdomen and sewn into this segment of presumed jejunum with a 4-0 PDS. This segment of bowel was sutured to the anterior abdominal wall with interrupted 3-0 silk. The abdomen was then irrigated and evacuated. #2 nylon sutures were used as retention sutures through the fascia. The previous hernia defect was closed laterally and the transverse fashion with number one PDS. The midline fascia was then reapproximated with running looped 0 PDS. Retention sutures were tied over bridges. The abdomen did not appear to be overly tight, and unfortunately another segment of Strattice did not appear to be a feasible area of closure. We were also reluctant to leave an open abdomen because of difficulty with the ostomies. Skin and subcutaneous tissues were packed with Betadine soaked Kerlix gauze and outer dressings applied. Patient was taken to the intensive care unit intubated.