lindacoder
Guest
I am now second guessing myself on this scenario and would appreciate any thoughts.
OPERATION: Diagnostic laparoscopy, then laparoscopic assisted sigmoidectomy with splenic flexure mobilization, rigid sigmoidoscope, diverting loop ileostomy and appendectomy.
In the supine position the abdomen was prepped and draped in the usual fashion. The abdomen was insufflated to 15 cm of pressure. There were some adhesions to the upper abdomen from a previous epigastric hernia repair. I was able to place a 10 m port in the right upper quadrant laterally. These adhesions were taken down usingn scissors with cautery.There was no bowel present; just omentum. After freeing that up adequately additoinal 5 mm port was placed in the right mid upper quadrant more medially. When I was looking back at the stomach there was no evidence of contamination or inflammation around the duodenum or the stomach. I then went ahead and looked down in the pelvis and thre was purulencce but not a significant amount. That fluid was extrracted and sent for culture. On evaluation I was able to see that there was thickening of his colon but no signs of any spillage. At this point I thought it was reasonable to go ahead and laparoscopically take down the spleninc flexure so that I would be able to make a smaller infraumbilical midline incision. I therefore mobilized the left colon; took the omentum off the transvers colon; took down the splenic flexure with the Harmonic. After adequately moblizing this, I assessed it further and I thought it would be reasonable to reset and even go ahead and do a primary anstomosis, with that because of his heart history that would give him a diverting loop ileostomy and this was based upon that he did not have any spillage offf and really minimal inflammation.
We went ahead and removed the ports and made an infraumbilical midline incision going through a 10 mm port that I had placed in the mid abdomen to help with the takedown of the splenic flexure. I then freed up the remainder of the attachments. The left ureter was palpated and well away from this. I then dissected down to the upper rectum where colon was all normal, and proximally as well. The mesentery was serially clamped, divided and ligated with 2-0 Vicryl. Dissection continued up to the rectum where it was normal. I divided that with a GIA blue load after milking the stool up into this proximal colon. The I chose a site on the left colon where the bowel was normal. This was opened and sized with a 33. The anvil was then brought through this and out through the side. A pursestring of 2-0 PDS was placed around this. The bowel was resected closing this off with a GIA75. The colon was sent for permanent. I went below and sized this. The EEA was then brought though the staple line. The two ends were then docked, approximated and fired after making sure there was no twisting. The EEA was removed. There were two intact donut rings. Irrigation was placed over anastomosis and the bowel was clamped proximal. Rigid sigmoidoscope did not show signs of an air leak. The irrigation was removed. I then went back up and buttressed with interrupted 3-0 silk anteriorly. On completion this rested without any tension. the bowel looked good. Again becauseof his cardiac disease and aware that he would not tolerate if he had a leak, I decided to go ahead and do the divertling loop ileostomy. etc........
Is this a laporoscopic sigmoidectomy or a laparoscopic converted to open sigmoidectomy?
THanks
OPERATION: Diagnostic laparoscopy, then laparoscopic assisted sigmoidectomy with splenic flexure mobilization, rigid sigmoidoscope, diverting loop ileostomy and appendectomy.
In the supine position the abdomen was prepped and draped in the usual fashion. The abdomen was insufflated to 15 cm of pressure. There were some adhesions to the upper abdomen from a previous epigastric hernia repair. I was able to place a 10 m port in the right upper quadrant laterally. These adhesions were taken down usingn scissors with cautery.There was no bowel present; just omentum. After freeing that up adequately additoinal 5 mm port was placed in the right mid upper quadrant more medially. When I was looking back at the stomach there was no evidence of contamination or inflammation around the duodenum or the stomach. I then went ahead and looked down in the pelvis and thre was purulencce but not a significant amount. That fluid was extrracted and sent for culture. On evaluation I was able to see that there was thickening of his colon but no signs of any spillage. At this point I thought it was reasonable to go ahead and laparoscopically take down the spleninc flexure so that I would be able to make a smaller infraumbilical midline incision. I therefore mobilized the left colon; took the omentum off the transvers colon; took down the splenic flexure with the Harmonic. After adequately moblizing this, I assessed it further and I thought it would be reasonable to reset and even go ahead and do a primary anstomosis, with that because of his heart history that would give him a diverting loop ileostomy and this was based upon that he did not have any spillage offf and really minimal inflammation.
We went ahead and removed the ports and made an infraumbilical midline incision going through a 10 mm port that I had placed in the mid abdomen to help with the takedown of the splenic flexure. I then freed up the remainder of the attachments. The left ureter was palpated and well away from this. I then dissected down to the upper rectum where colon was all normal, and proximally as well. The mesentery was serially clamped, divided and ligated with 2-0 Vicryl. Dissection continued up to the rectum where it was normal. I divided that with a GIA blue load after milking the stool up into this proximal colon. The I chose a site on the left colon where the bowel was normal. This was opened and sized with a 33. The anvil was then brought through this and out through the side. A pursestring of 2-0 PDS was placed around this. The bowel was resected closing this off with a GIA75. The colon was sent for permanent. I went below and sized this. The EEA was then brought though the staple line. The two ends were then docked, approximated and fired after making sure there was no twisting. The EEA was removed. There were two intact donut rings. Irrigation was placed over anastomosis and the bowel was clamped proximal. Rigid sigmoidoscope did not show signs of an air leak. The irrigation was removed. I then went back up and buttressed with interrupted 3-0 silk anteriorly. On completion this rested without any tension. the bowel looked good. Again becauseof his cardiac disease and aware that he would not tolerate if he had a leak, I decided to go ahead and do the divertling loop ileostomy. etc........
Is this a laporoscopic sigmoidectomy or a laparoscopic converted to open sigmoidectomy?
THanks
