Hello. I would love any advice on this one.
PROCEDURE: Exploratory laparotomy
Lysis of adhesions
Left colon resection
Sigmoid resection
Transverse colostomy, Hartmann Pouch
Application of abthera wound vac
PROCEDURE:
Patient is a 59 yr old male who presented with findings consistent with a perforated viscus. He was consented for an exploratory laparotomy. Risks and benefits were explained. Patient was taken emergently to the OR. He was placed in the supine position. General endotracheal anesthesia was induced. A foley catheter was placed. The abdomen was prepped and draped in the standard sterile fashion.
A midline incision was made with a #10 blade. This incision was taken through the subcutaneous tissues and to the linea alba. Both edges of the fascia were grasped with Kochers. An incision was then made into the peritoneum. The pneumoperitoneum was gradually decompressed. The entire length of the incision was then opened to gain access to the peritoneal cavity. Patient had some small bowel and omental adhesions to the abdominal wall. Careful adhesiolysis was performed. The small bowel was seen to be distended and edematous. There was obvious large amounts of purulent fluid in the abdomen. This was suctioned. Swabs were taken and sent for gram stain and cultures. Based on the patient's history, the initial suspicion was for a perforated sigmoid diverticulum. Attention was quickly turned to the sigmoid colon. To enhance exposure a Bookwalter retractor was applied. The sigmoid was quickly identified. It was seen to be markedly distended proximally and as far up as the transverse colon. There were 3 separate loops of small bowel that seemed to be adherent to the mesentery of the sigmoid. This area had extremely dense adhesions and was hard and fibrotic.
Care was taken to dissect off the loops of bowel from the fibrotic area in the sigmoid mesocolon. These bowel loops were densely adherent such that in an effort to dissect them off a small enterotomy was created on each. The enterotomies were repaired with interrupted 3-0 silks in a Lembert fashion. After dissecting the small bowel off the sigmoid mesocolon malleable retractors were applied on the bowel to enhance exposure. The white line of Toldt was then incised. Care was taken to carefully mobilize the sigmoid in a lateral to medial direction. Progress was significantly limited by the densely fibrotic mesocolon. To facilitate the dissection the sigmoid was divided proximal to the affected area. This was achieved with 3 firings of a 60/4.8mm stapler. The mesocolon was carefully divided with a combination of the enseal device, electrocautery and sharp dissection. Any bleeding encountered was immediately controlled with a 3-0 vicryl suture ligation. Eventually the fibrotic strictured segment of the sigmoid was freed. Distal to it was normal sigmoid. The distal sigmoid was divided with a 60/4.8mm stapler. The sigmoid specimen was passed off.
The rest of the abdomen was then inspected for the potential source of the purulent drainage and site of perforation. It was found in the splenic flexure. The transverse colon was divided just distal to the middle colics with a 60/3.5mm stapler. The mesocolon and greater omentum were divided with the enseal. In this manner the entire left colon was resected and passed off the table. The abdomen was then washed out with 6 L of warm saline. At this point in the case the patient had received about 9L of fluids and was on pressors. The bowels were very edematous.
A spot was chosen in the LUQ for the colostomy. A circular skin incision was made and dissection continued down to the rectus. A cruciate incision was made in the rectus. The transverse colon end was pulled through this incision. It was then held in place with Babcocks. The abdomen was covered temporarily with a towel to avoid contamination. The staple end of the colon was excised. 3-0 vicryl sutures were then placed the colon mucosa proximal serosa and the skin to evert the colostomy end. The ostomy appliance was placed. The surgical team then changed gloves. An abthera wound vac was applied appropriately. The sponge and instrument count was found to be complete. The patient was kept intubated and transferred to the ICU.
PROCEDURE: Exploratory laparotomy
Lysis of adhesions
Left colon resection
Sigmoid resection
Transverse colostomy, Hartmann Pouch
Application of abthera wound vac
PROCEDURE:
Patient is a 59 yr old male who presented with findings consistent with a perforated viscus. He was consented for an exploratory laparotomy. Risks and benefits were explained. Patient was taken emergently to the OR. He was placed in the supine position. General endotracheal anesthesia was induced. A foley catheter was placed. The abdomen was prepped and draped in the standard sterile fashion.
A midline incision was made with a #10 blade. This incision was taken through the subcutaneous tissues and to the linea alba. Both edges of the fascia were grasped with Kochers. An incision was then made into the peritoneum. The pneumoperitoneum was gradually decompressed. The entire length of the incision was then opened to gain access to the peritoneal cavity. Patient had some small bowel and omental adhesions to the abdominal wall. Careful adhesiolysis was performed. The small bowel was seen to be distended and edematous. There was obvious large amounts of purulent fluid in the abdomen. This was suctioned. Swabs were taken and sent for gram stain and cultures. Based on the patient's history, the initial suspicion was for a perforated sigmoid diverticulum. Attention was quickly turned to the sigmoid colon. To enhance exposure a Bookwalter retractor was applied. The sigmoid was quickly identified. It was seen to be markedly distended proximally and as far up as the transverse colon. There were 3 separate loops of small bowel that seemed to be adherent to the mesentery of the sigmoid. This area had extremely dense adhesions and was hard and fibrotic.
Care was taken to dissect off the loops of bowel from the fibrotic area in the sigmoid mesocolon. These bowel loops were densely adherent such that in an effort to dissect them off a small enterotomy was created on each. The enterotomies were repaired with interrupted 3-0 silks in a Lembert fashion. After dissecting the small bowel off the sigmoid mesocolon malleable retractors were applied on the bowel to enhance exposure. The white line of Toldt was then incised. Care was taken to carefully mobilize the sigmoid in a lateral to medial direction. Progress was significantly limited by the densely fibrotic mesocolon. To facilitate the dissection the sigmoid was divided proximal to the affected area. This was achieved with 3 firings of a 60/4.8mm stapler. The mesocolon was carefully divided with a combination of the enseal device, electrocautery and sharp dissection. Any bleeding encountered was immediately controlled with a 3-0 vicryl suture ligation. Eventually the fibrotic strictured segment of the sigmoid was freed. Distal to it was normal sigmoid. The distal sigmoid was divided with a 60/4.8mm stapler. The sigmoid specimen was passed off.
The rest of the abdomen was then inspected for the potential source of the purulent drainage and site of perforation. It was found in the splenic flexure. The transverse colon was divided just distal to the middle colics with a 60/3.5mm stapler. The mesocolon and greater omentum were divided with the enseal. In this manner the entire left colon was resected and passed off the table. The abdomen was then washed out with 6 L of warm saline. At this point in the case the patient had received about 9L of fluids and was on pressors. The bowels were very edematous.
A spot was chosen in the LUQ for the colostomy. A circular skin incision was made and dissection continued down to the rectus. A cruciate incision was made in the rectus. The transverse colon end was pulled through this incision. It was then held in place with Babcocks. The abdomen was covered temporarily with a towel to avoid contamination. The staple end of the colon was excised. 3-0 vicryl sutures were then placed the colon mucosa proximal serosa and the skin to evert the colostomy end. The ostomy appliance was placed. The surgical team then changed gloves. An abthera wound vac was applied appropriately. The sponge and instrument count was found to be complete. The patient was kept intubated and transferred to the ICU.