mfournier
Networker
Hello Everyone:
Was wondering if someone can take a peek at this note. I have asked provider to verify if this was truly a "convert to open" but not getting an answer :-(
I do not see where he converted to an open sigmoid colectomy. I only see the laparoscopic approach
Operative technique: After obtaining adequate informed signed the patient was taken the operating theater. Patient was positioned in the supine position with arms outstretched on padded arm boards. Given a limited extension of the right elbow, the right arm cannot be tucked safely against the right side and was also placed on an armboard with additional bolsters underneath the forearm and wrist given the lack of full extension. After induction of general endotracheal anesthesia, the urology team entered the operating theater and placed bilateral ureteral stents. Please see this operative note for full detail. Thereafter, I entered the operating theater and positioned in position in the low lithotomy position and padded yellowfin stirrups. The arms were placed outstretched on the padded arm boards as prior. Surgical timeout was conducted per the institutional protocol, once all parties were satisfied we elected to proceed. The abdomen widely prepped and draped in standard sterile surgical fashion. Final pre-incisional pause was then conducted.
Term attention the low midline making a 7 cm incision using #15 blade and dissected down through subcutaneous tissues until the midline fascia was encountered. Was incised along the length of skin incision. The incision was sized to fit my hand, for the purpose of placing HandPort. I did place my hand into abdominal cavity, and begin a general assessment. The mid sigmoid colon was densely here into the left pelvic brim. Minimal additional adhesions however, and I felt we could proceed laparoscopically. The Alexis wound retractor was placed into the wound, and position appropriately. A 1012 trocar was placed superior to the umbilicus through another incision made with a #15 blade. The 10 mm trocar was directed into the abdomen with my palm as of the backstop inside the patient. The abdomen was insufflated with CO2 gas and a 10 mm, 30 degree, camera was introduced umbilical port. The GelPort was placed over the wound retractor. I then placed a 5 mm port in the right lower quadrant lateral to inferior epigastric vessels under direct visualization through a 5 mm stab incision.
Turned attention to the left pelvic brim, the white line of Toldt was identified superior to the area of inflammatory change and this was opened widely from the left pelvic brim all the way up to the inferior aspect of the splenic flexure. We came back inferiorly continued the plane of dissection into the area of maximal inflammation. Visualization became difficult at this time, and I transition to hand cystectomy using my left hand to guide the dissection through the area, with the LigaSure directed appropriately with manual assistance to continue mobilization of the sigmoid colon away from the left pelvic brim. Once this was free, we turned my attention back proximally and continued to take down the splenic flexure until sufficient mobilization was noted. We turned attention back to the pelvic brim. At this point the trochars were backed up to flush with the abdominal wall, and insufflation was reduced and I proceeded under direct visualization as a left pelvic brim was nicely visualized through the HandPort additional adhesions were taken using the electrocautery pencil, the left ureter was identified and preserved as well as the left tube and ovary. We continued the dissection up and over the pelvic brim into the avascular TME plane along the left lateral aspect of the rectum. The entire descending and sigmoid colon was now very nicely mobilized. Distal point of division was chosen and anatomically this was done at the location of the coalescence of the tenia coli. A window was made the mesentery here and this mesenteric window was extended. A contour stapler with a blue load was directed across the rectum here, closed and fired. A proximal point of division was chosen and palpably normal distal descending colon and the window was extended with LigaSure. The remaining mesentery was taken with a combination of LigaSure, 2 locations 0 Vicryl ties on the stay side and LigaSure on the specimen side. I now turned my attention to evaluation of the rectal stump. 25 then 29 mm EEA sizers were delivered to the apex of the rectal stump. As I delivered the sizers appreciated what appeared to be a diverticulum along the proximal portion of the perceived rectum. This suggested a small remnant portion of sigmoid colon remained here despite the visual confirmation of the coalescent tenia coli. I elected to evaluate this endoscopically introducing the colonoscope per anus all the way up to the stump, indeed the area of concern was identified as a diverticulum and I determined the need to take additional length here. Again mesenteric windows were made in these mesenteric windows develop with the LigaSure. A second firing the contour stapler was done below the diverticulum now on true anatomic rectum. Stapler was fired and the specimen was removed. I now turned my attention to upstream, and at the proximal point of division divided the colon using the electrocautery pencil. A 29 mm EEA stapler was requested. The 29 mm EEA anvil was secured into the distal descending colon using a 2-0 Prolene pursestring suture. The primary specimen was now free and passed off the field labeled sigmoid colon stitch marks distal, the additional segment of rectosigmoid was also passed off the specimen #2, stitch marks distal. I then went between the legs delivering the EEA stapler to the apex of the rectal stump. The stapler spike was brought through just posterior to the transverse staple line under direct visualization. The anvil and spike were made in usual manner and the stapler was closed under direct visualization. The left ureter and pelvic brim structures were Well clear, the mesenteric orientation was preserved. We were also well clear of the vagina and the adnexa bilaterally. The stapler was now fired and withdrawn in usual manner. 2 intact and generous anastomotic rings were noted. Irrigant was instilled into the pelvis and the anastomosis was submerged. The distal descending colon was occluded digitally above the anastomosis. Flexible colonoscope was introduced per anus advanced up to the anastomosis and more proximal, scope was then reduced, anastomosis was widely patent. It was hemostatic. Air was instilled into the lumen under pressure. Absolutely no extravasation of air was noted during the leak insufflation test. Having now satisfied the leak insufflation test air was removed, and the scope was ultimately removed per anus. The irrigant was removed from the pelvis. The field was hemostatic. Estimated blood loss at this time 25 cc. A sponge instrument chart count was reported as correct, and we transitioned to the closing bundle protocol. The midline fascia was reapproximated using #1 looped PDS 1 begun superiorly, 1 begun inferiorly and the 2 joined in the inferior portion of wound. Surgical staples used to reapproximate the skin edges at the midline wound, and the right lower quadrant port site. A Prevena wound dressing was placed in the midline, Telfa Tegaderm in the right lower quadrant. Final sponge instrument sharp counts reported as correct. The case was now complete. Anesthesia was reversed, the patient was extubated, the patient was taken to the postanesthesia care in stable condition having tolerated the procedure well with no apparent immediate complication.
Any clarification would be grateful appreciated.
Have a good day everyone.
Miriam
Was wondering if someone can take a peek at this note. I have asked provider to verify if this was truly a "convert to open" but not getting an answer :-(
I do not see where he converted to an open sigmoid colectomy. I only see the laparoscopic approach
Operative technique: After obtaining adequate informed signed the patient was taken the operating theater. Patient was positioned in the supine position with arms outstretched on padded arm boards. Given a limited extension of the right elbow, the right arm cannot be tucked safely against the right side and was also placed on an armboard with additional bolsters underneath the forearm and wrist given the lack of full extension. After induction of general endotracheal anesthesia, the urology team entered the operating theater and placed bilateral ureteral stents. Please see this operative note for full detail. Thereafter, I entered the operating theater and positioned in position in the low lithotomy position and padded yellowfin stirrups. The arms were placed outstretched on the padded arm boards as prior. Surgical timeout was conducted per the institutional protocol, once all parties were satisfied we elected to proceed. The abdomen widely prepped and draped in standard sterile surgical fashion. Final pre-incisional pause was then conducted.
Term attention the low midline making a 7 cm incision using #15 blade and dissected down through subcutaneous tissues until the midline fascia was encountered. Was incised along the length of skin incision. The incision was sized to fit my hand, for the purpose of placing HandPort. I did place my hand into abdominal cavity, and begin a general assessment. The mid sigmoid colon was densely here into the left pelvic brim. Minimal additional adhesions however, and I felt we could proceed laparoscopically. The Alexis wound retractor was placed into the wound, and position appropriately. A 1012 trocar was placed superior to the umbilicus through another incision made with a #15 blade. The 10 mm trocar was directed into the abdomen with my palm as of the backstop inside the patient. The abdomen was insufflated with CO2 gas and a 10 mm, 30 degree, camera was introduced umbilical port. The GelPort was placed over the wound retractor. I then placed a 5 mm port in the right lower quadrant lateral to inferior epigastric vessels under direct visualization through a 5 mm stab incision.
Turned attention to the left pelvic brim, the white line of Toldt was identified superior to the area of inflammatory change and this was opened widely from the left pelvic brim all the way up to the inferior aspect of the splenic flexure. We came back inferiorly continued the plane of dissection into the area of maximal inflammation. Visualization became difficult at this time, and I transition to hand cystectomy using my left hand to guide the dissection through the area, with the LigaSure directed appropriately with manual assistance to continue mobilization of the sigmoid colon away from the left pelvic brim. Once this was free, we turned my attention back proximally and continued to take down the splenic flexure until sufficient mobilization was noted. We turned attention back to the pelvic brim. At this point the trochars were backed up to flush with the abdominal wall, and insufflation was reduced and I proceeded under direct visualization as a left pelvic brim was nicely visualized through the HandPort additional adhesions were taken using the electrocautery pencil, the left ureter was identified and preserved as well as the left tube and ovary. We continued the dissection up and over the pelvic brim into the avascular TME plane along the left lateral aspect of the rectum. The entire descending and sigmoid colon was now very nicely mobilized. Distal point of division was chosen and anatomically this was done at the location of the coalescence of the tenia coli. A window was made the mesentery here and this mesenteric window was extended. A contour stapler with a blue load was directed across the rectum here, closed and fired. A proximal point of division was chosen and palpably normal distal descending colon and the window was extended with LigaSure. The remaining mesentery was taken with a combination of LigaSure, 2 locations 0 Vicryl ties on the stay side and LigaSure on the specimen side. I now turned my attention to evaluation of the rectal stump. 25 then 29 mm EEA sizers were delivered to the apex of the rectal stump. As I delivered the sizers appreciated what appeared to be a diverticulum along the proximal portion of the perceived rectum. This suggested a small remnant portion of sigmoid colon remained here despite the visual confirmation of the coalescent tenia coli. I elected to evaluate this endoscopically introducing the colonoscope per anus all the way up to the stump, indeed the area of concern was identified as a diverticulum and I determined the need to take additional length here. Again mesenteric windows were made in these mesenteric windows develop with the LigaSure. A second firing the contour stapler was done below the diverticulum now on true anatomic rectum. Stapler was fired and the specimen was removed. I now turned my attention to upstream, and at the proximal point of division divided the colon using the electrocautery pencil. A 29 mm EEA stapler was requested. The 29 mm EEA anvil was secured into the distal descending colon using a 2-0 Prolene pursestring suture. The primary specimen was now free and passed off the field labeled sigmoid colon stitch marks distal, the additional segment of rectosigmoid was also passed off the specimen #2, stitch marks distal. I then went between the legs delivering the EEA stapler to the apex of the rectal stump. The stapler spike was brought through just posterior to the transverse staple line under direct visualization. The anvil and spike were made in usual manner and the stapler was closed under direct visualization. The left ureter and pelvic brim structures were Well clear, the mesenteric orientation was preserved. We were also well clear of the vagina and the adnexa bilaterally. The stapler was now fired and withdrawn in usual manner. 2 intact and generous anastomotic rings were noted. Irrigant was instilled into the pelvis and the anastomosis was submerged. The distal descending colon was occluded digitally above the anastomosis. Flexible colonoscope was introduced per anus advanced up to the anastomosis and more proximal, scope was then reduced, anastomosis was widely patent. It was hemostatic. Air was instilled into the lumen under pressure. Absolutely no extravasation of air was noted during the leak insufflation test. Having now satisfied the leak insufflation test air was removed, and the scope was ultimately removed per anus. The irrigant was removed from the pelvis. The field was hemostatic. Estimated blood loss at this time 25 cc. A sponge instrument chart count was reported as correct, and we transitioned to the closing bundle protocol. The midline fascia was reapproximated using #1 looped PDS 1 begun superiorly, 1 begun inferiorly and the 2 joined in the inferior portion of wound. Surgical staples used to reapproximate the skin edges at the midline wound, and the right lower quadrant port site. A Prevena wound dressing was placed in the midline, Telfa Tegaderm in the right lower quadrant. Final sponge instrument sharp counts reported as correct. The case was now complete. Anesthesia was reversed, the patient was extubated, the patient was taken to the postanesthesia care in stable condition having tolerated the procedure well with no apparent immediate complication.
Any clarification would be grateful appreciated.
Have a good day everyone.
Miriam