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PREOP and POSTOPERATIVE DIAGNOSIS: Colostomy status.
PROCEDURES PERFORMED:
Exploratory laparotomy.
Low anterior resection with low pelvic anastomosis.
Parastomal hernia repair, incarcerated.
Complete mobilization of splenic flexure.
Colostomy takedown.
Placement of wound VAC.
Rigid proctoscopy.
SPECIMENS:
Colostomy.
Rectal stump.
Hernia sac.
OPERATIVE FINDINGS: Very mild intraabdominal adhesions. No signs of residual or recurrent cancer. Healthy left lower quadrant colostomy with a large incarcerated parastomal hernia. The pelvic stump measured about 10 cm and was easily identified in the base of the pelvis.
DETAILS OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and underwent induction of general anesthesia. She was placed in the low modified lithotomy position with all pressure points were padded. Her abdomen was prepped and draped in standard sterile surgical fashion. Her prior midline incision was opened and the abdomen was carefully entered and explored revealing findings as described above. The Bookwalter retractor was utilized and mild adhesions were divided pulling the small bowel out of the pelvis. An EEA sizer inserted into the anus and up to the rectal apex assisted in dissection of the rectum. I was able to enter the presacral plane and developed this plane down to the levators. Corresponding lateral dissections were performed on either side, and a minimal anterior dissection was performed. Rectal stump was well clear of the vagina. The mesorectum was divided approximately cm distal to the apex of the stump and a contour stapler was used to divide the stump at this level.
At this point, I turned my attention toward the colostomy. The mucocutaneous junction was divided with electrocautery and the colon was dissected free from the hernia sac after reduction of the small bowel. Complete mobilization of the splenic flexure was then undertaken in lateral to medial fashion with high ligation of both the IMA and IMV. The base of the mesentery was divided all the way up to the middle colic vessels, which were carefully preserved. The lesser sac was opened in order to fully mobilize the flexure. After these maneuvers, we had more than adequate length of colon to reach deep into the pelvis with absolute 0 tension. Excellent blood supply was evident at the end of the colon. A line of planned anastomosis was then identified in the colon conduit and the mesocolon was divided off at this level with the LigaSure. A pursestring of a 28 mm EEA stapler was then affixed to the proximal colon and then the stapler was inserted through the anus up to the rectal apex and the spike was advanced, which was then coupled with the stapler. After ensuring no twisting or incorporation of extraneous tissue, the stapler was closed. The vagina was again found to be free and clear from the anastomosis. The stapler was fired. Underwater leak testing was performed, which revealed no leaking. Anastomosis was then measured with rigid proctoscope and found the anastomosis at about 9 to 10 cm from the anal verge. We had a tension-free well-vascularized comfortable anastomosis above a cm and with a clean and healthy tissue planes on both ends, I felt comfortable not performing anteversion. A 19 round Blake drain was placed in the pelvis and hemostasis was observed throughout the abdomen. The hernia site was closed in 2 layers with running #1 PDS, and the hernia sac was dissected free and sent as a specimen. A small amount of skin was also removed as this was very redundant over the area of the hernia. The fascia of the midline was closed with running #1 looped PDS suture. The subcutaneous tissues were irrigated. The skin was closed with clips. The wound VAC was then cut into a circle about 8 cm in diameter and inserted into the parastomal hernia site and fixed to the skin in standard fashion. The patient tolerated the procedure well. All sponge and instrument counts were performed x2 and reported to me as correct at the conclusion of the procedure.
PREOP and POSTOPERATIVE DIAGNOSIS: Colostomy status.
PROCEDURES PERFORMED:
Exploratory laparotomy.
Low anterior resection with low pelvic anastomosis.
Parastomal hernia repair, incarcerated.
Complete mobilization of splenic flexure.
Colostomy takedown.
Placement of wound VAC.
Rigid proctoscopy.
SPECIMENS:
Colostomy.
Rectal stump.
Hernia sac.
OPERATIVE FINDINGS: Very mild intraabdominal adhesions. No signs of residual or recurrent cancer. Healthy left lower quadrant colostomy with a large incarcerated parastomal hernia. The pelvic stump measured about 10 cm and was easily identified in the base of the pelvis.
DETAILS OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and underwent induction of general anesthesia. She was placed in the low modified lithotomy position with all pressure points were padded. Her abdomen was prepped and draped in standard sterile surgical fashion. Her prior midline incision was opened and the abdomen was carefully entered and explored revealing findings as described above. The Bookwalter retractor was utilized and mild adhesions were divided pulling the small bowel out of the pelvis. An EEA sizer inserted into the anus and up to the rectal apex assisted in dissection of the rectum. I was able to enter the presacral plane and developed this plane down to the levators. Corresponding lateral dissections were performed on either side, and a minimal anterior dissection was performed. Rectal stump was well clear of the vagina. The mesorectum was divided approximately cm distal to the apex of the stump and a contour stapler was used to divide the stump at this level.
At this point, I turned my attention toward the colostomy. The mucocutaneous junction was divided with electrocautery and the colon was dissected free from the hernia sac after reduction of the small bowel. Complete mobilization of the splenic flexure was then undertaken in lateral to medial fashion with high ligation of both the IMA and IMV. The base of the mesentery was divided all the way up to the middle colic vessels, which were carefully preserved. The lesser sac was opened in order to fully mobilize the flexure. After these maneuvers, we had more than adequate length of colon to reach deep into the pelvis with absolute 0 tension. Excellent blood supply was evident at the end of the colon. A line of planned anastomosis was then identified in the colon conduit and the mesocolon was divided off at this level with the LigaSure. A pursestring of a 28 mm EEA stapler was then affixed to the proximal colon and then the stapler was inserted through the anus up to the rectal apex and the spike was advanced, which was then coupled with the stapler. After ensuring no twisting or incorporation of extraneous tissue, the stapler was closed. The vagina was again found to be free and clear from the anastomosis. The stapler was fired. Underwater leak testing was performed, which revealed no leaking. Anastomosis was then measured with rigid proctoscope and found the anastomosis at about 9 to 10 cm from the anal verge. We had a tension-free well-vascularized comfortable anastomosis above a cm and with a clean and healthy tissue planes on both ends, I felt comfortable not performing anteversion. A 19 round Blake drain was placed in the pelvis and hemostasis was observed throughout the abdomen. The hernia site was closed in 2 layers with running #1 PDS, and the hernia sac was dissected free and sent as a specimen. A small amount of skin was also removed as this was very redundant over the area of the hernia. The fascia of the midline was closed with running #1 looped PDS suture. The subcutaneous tissues were irrigated. The skin was closed with clips. The wound VAC was then cut into a circle about 8 cm in diameter and inserted into the parastomal hernia site and fixed to the skin in standard fashion. The patient tolerated the procedure well. All sponge and instrument counts were performed x2 and reported to me as correct at the conclusion of the procedure.