Callieb
Guest
I could really use some help on this one. Patient's diagnosis is ileosigmoid fistula with ileoascending fistula secondary to Crohn's with phlegmon involving terminal ileum at ileocecal junction.
Procedure-exp laparotomy, ileoascending colectomy with end to side ileoascending colostomy, partial ileal resection with Heineke Mikulicz type reconstruction approx 6" from area of Crohn's secondary to ileoileal fistula. Partial resectons sigmoid rectum at previous anastomosis secondary to defect from ileosigmoid fistula with low anterior Baker type anastomosis. (In 2004 patient had sm bowel resection and sigmoidectomy)
Procedure Note - Midline incision made from umbilicus to pubis excising old midline scar. Peritoneal cavity was entered sharply. Adhesions taken down from anterior abdominal wall. On inspection gallbladder & liver normal. Small bowel run from ligament of Treitz to terminal ileum and there appeared to be a phlegmon involving terminal ileum and with loop of bowel attached approx 6-8" proximal to that consistent with ileoileal fistula. Also found colon adherent to this phlegmonous process consistent with visualized ileoascending colic fistuta tract. Also adhesions to distal sigmoid adn previous anastomsis site and fistulous tract in this regions. Fistula to distal sigmoid was dismantled cutting across it and approx dime size defect was palpable in posterior aspect of what appeared to be previous EEA anastomosis from the fistulous tract. Attention was turned to terminal ileum and right colon mobilized from retroperitoneum. What appeared to be an ileo-ileo fistula was seperated and outer 2/3 of ileum, approx 6-8" from ileocecal valve was debrided of tissue. It did not appear to be consistent with Crohn's at that level. Defect repaired transversely in a Heineke Mikulicz fashion in two layers. Attention then directed to terminal ileum, short segment, Crohn's segment was identified consistent with phlegmon. GI stapling device fired across ascending colon and ileum approx 5-6" from ileocecal valve. Mesentary divided between right inguinal clamps. At this point, distal end of colon oversewn. Specimen sent for path confirming Crohn's. End to side ileoascending colostomy was fashioned in two layers. Attention directed to sigmoid rectum. No other evidence of Crohns in small bowel noted. Lateral peritoneal attachments and distal sigmoid anastomosis mobilized. Dense tissue from chronic fistula tract was posteriorly separated from presacral space and ultimately able to mobile rectum up into wound somewhat. GIA55 stapling device fired across distal sigmoid approx 1.5 - 2" from anastomosis, proximal end oversewn. Mobilization with incision of white line in total was carried out, so as to perform a new anastomosis in this region. At level of previous EEA staple line this was dismantled using cautery from the rectum and sent for permanent path. Baker anastomosis was constructed. Sigmoid rectal was obtained relatively low in cul de sac. Some of tissue at base of bladder was pulled over anastomosis and sutured to anterior wall of Baker anastomosis covering our suture line and making it retroperitoneal well away from uterus, tubes adn ovaries. Ovaries were somethat adherent to phlegmon and care was taken to dissect off the fallopian tubes and ovaries so as not to disrupt th;em in any way.
Procedure-exp laparotomy, ileoascending colectomy with end to side ileoascending colostomy, partial ileal resection with Heineke Mikulicz type reconstruction approx 6" from area of Crohn's secondary to ileoileal fistula. Partial resectons sigmoid rectum at previous anastomosis secondary to defect from ileosigmoid fistula with low anterior Baker type anastomosis. (In 2004 patient had sm bowel resection and sigmoidectomy)
Procedure Note - Midline incision made from umbilicus to pubis excising old midline scar. Peritoneal cavity was entered sharply. Adhesions taken down from anterior abdominal wall. On inspection gallbladder & liver normal. Small bowel run from ligament of Treitz to terminal ileum and there appeared to be a phlegmon involving terminal ileum and with loop of bowel attached approx 6-8" proximal to that consistent with ileoileal fistula. Also found colon adherent to this phlegmonous process consistent with visualized ileoascending colic fistuta tract. Also adhesions to distal sigmoid adn previous anastomsis site and fistulous tract in this regions. Fistula to distal sigmoid was dismantled cutting across it and approx dime size defect was palpable in posterior aspect of what appeared to be previous EEA anastomosis from the fistulous tract. Attention was turned to terminal ileum and right colon mobilized from retroperitoneum. What appeared to be an ileo-ileo fistula was seperated and outer 2/3 of ileum, approx 6-8" from ileocecal valve was debrided of tissue. It did not appear to be consistent with Crohn's at that level. Defect repaired transversely in a Heineke Mikulicz fashion in two layers. Attention then directed to terminal ileum, short segment, Crohn's segment was identified consistent with phlegmon. GI stapling device fired across ascending colon and ileum approx 5-6" from ileocecal valve. Mesentary divided between right inguinal clamps. At this point, distal end of colon oversewn. Specimen sent for path confirming Crohn's. End to side ileoascending colostomy was fashioned in two layers. Attention directed to sigmoid rectum. No other evidence of Crohns in small bowel noted. Lateral peritoneal attachments and distal sigmoid anastomosis mobilized. Dense tissue from chronic fistula tract was posteriorly separated from presacral space and ultimately able to mobile rectum up into wound somewhat. GIA55 stapling device fired across distal sigmoid approx 1.5 - 2" from anastomosis, proximal end oversewn. Mobilization with incision of white line in total was carried out, so as to perform a new anastomosis in this region. At level of previous EEA staple line this was dismantled using cautery from the rectum and sent for permanent path. Baker anastomosis was constructed. Sigmoid rectal was obtained relatively low in cul de sac. Some of tissue at base of bladder was pulled over anastomosis and sutured to anterior wall of Baker anastomosis covering our suture line and making it retroperitoneal well away from uterus, tubes adn ovaries. Ovaries were somethat adherent to phlegmon and care was taken to dissect off the fallopian tubes and ovaries so as not to disrupt th;em in any way.
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