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NAME OF OPERATION
1. Exploratory laparotomy.
2. Subtotal colectomy.
3. End colostomy.
INDICATIONS
This was an 83-year-old female who has had abdominal pain for the last 4 days. She presented to the Emergency Room. They did a CAT scan which showed perforation with a large fecal bolus in the right lower quadrant. The patient was brought in for urgent exploratory laparotomy.
DESCRIPTION OF OPERATION
The patient was placed in the lithotomy position. General anesthesia was induced. Preoperative antibiotics were given. Foley catheter and nasogastric tubes were placed. The abdomen was prepped and draped in the usual sterile fashion. A vertical skin incision was made. This was deepened through the subcutaneous tissues and hemostasis was achieved within the wound. The linea alba was identified, incised and the peritoneal cavity was entered. The abdomen was explored. There was noted to be putrid smell upon entering the peritoneal cavity. Adhesions were lysed sharply under direct vision with Metzenbaum scissors. The abdominal cavity was inspected for gross abnormalities. The sigmoid colon was perforated and there was noted to be gross fecal contamination in the peritoneal cavity. This was removed by hand. Approximately 500 mL of formed stool was removed from the peritoneal cavity. The small bowel was inspected. No evidence of any other pathology was noted. Initially, the left colon was mobilized by incising the peritoneal attachment laterally to the splenic flexure. Because of the gross fecal contamination, a point distal to the perforation was selected and using a contour stapling device, a window in the mesentery was made at the distal sigmoid colon and the wound over the mesentery was chosen and a contour stapling device was fired. The mesentery then was carefully dissected away and noting a large perforation within the sigmoid colon. The mesentery was released using a LigaSure coagulation device and the left colon was medialized medially. As dissection continues, it was noted that a gross portion of the colon appeared nonviable. Careful dissection off the splenic flexure carrying through the transverse colon down off the hepatic flexure using LigaSure coagulation device to divide the mesentery and the greater sac was brought and a point of transection was desperately tried to be found. The fluorescein was injected and a Wood lamp was brought in and it noted that only the ascending colon was viable. Everything else did not light up and became darkened as dissection continued. A contour stapling device was then fired across distal to the cecum in the first portion of the ascending colon. The remainder of the mesentery was divided and the specimen subtotal colectomy was removed. Because of the gross fecal contamination, it was noted that no anastomosis should be attempted, especially considering the uncertainty of the viability of the colon. Once this was done, approximately 20 liters of irrigation were used to clean out the peritoneal cavity and suction out. The proximal colon reached easily the proposed colostomy site without tension. A disk of skin was removed from the colostomy site and the right lower quadrant incision was deepened through all layers of the abdominal wall and dilated to accommodate two of my fingers. Colon was passed out through the ostomy site without torsion or tension. It was tacked to the fascia with 3-0 Vicryl sutures. Two closed suction drains were placed, one in the left upper quadrant and one in the pelvis, and brought through separate stab wound incisions lateral to the incision. These were secured with 3-0 nylon. Attention was then turned to the peritoneal cavity fascial area, where a looped 0-PDS was used to approximate the fascia. The wound then was irrigated copiously with another liter of irrigation and stapled loosely skin edges together. The wound was then packed with Silvercel rope packing and then a silver wound V.A.C. was placed. The colostomy was matured with multiple interrupted sutures of 3-0 Vicryl and the ostomy bag was applied. The patient tolerated the procedure well, and was wheeled to the Post Anesthesia Care Unit in stable condition.
NAME OF OPERATION
1. Exploratory laparotomy.
2. Subtotal colectomy.
3. End colostomy.
INDICATIONS
This was an 83-year-old female who has had abdominal pain for the last 4 days. She presented to the Emergency Room. They did a CAT scan which showed perforation with a large fecal bolus in the right lower quadrant. The patient was brought in for urgent exploratory laparotomy.
DESCRIPTION OF OPERATION
The patient was placed in the lithotomy position. General anesthesia was induced. Preoperative antibiotics were given. Foley catheter and nasogastric tubes were placed. The abdomen was prepped and draped in the usual sterile fashion. A vertical skin incision was made. This was deepened through the subcutaneous tissues and hemostasis was achieved within the wound. The linea alba was identified, incised and the peritoneal cavity was entered. The abdomen was explored. There was noted to be putrid smell upon entering the peritoneal cavity. Adhesions were lysed sharply under direct vision with Metzenbaum scissors. The abdominal cavity was inspected for gross abnormalities. The sigmoid colon was perforated and there was noted to be gross fecal contamination in the peritoneal cavity. This was removed by hand. Approximately 500 mL of formed stool was removed from the peritoneal cavity. The small bowel was inspected. No evidence of any other pathology was noted. Initially, the left colon was mobilized by incising the peritoneal attachment laterally to the splenic flexure. Because of the gross fecal contamination, a point distal to the perforation was selected and using a contour stapling device, a window in the mesentery was made at the distal sigmoid colon and the wound over the mesentery was chosen and a contour stapling device was fired. The mesentery then was carefully dissected away and noting a large perforation within the sigmoid colon. The mesentery was released using a LigaSure coagulation device and the left colon was medialized medially. As dissection continues, it was noted that a gross portion of the colon appeared nonviable. Careful dissection off the splenic flexure carrying through the transverse colon down off the hepatic flexure using LigaSure coagulation device to divide the mesentery and the greater sac was brought and a point of transection was desperately tried to be found. The fluorescein was injected and a Wood lamp was brought in and it noted that only the ascending colon was viable. Everything else did not light up and became darkened as dissection continued. A contour stapling device was then fired across distal to the cecum in the first portion of the ascending colon. The remainder of the mesentery was divided and the specimen subtotal colectomy was removed. Because of the gross fecal contamination, it was noted that no anastomosis should be attempted, especially considering the uncertainty of the viability of the colon. Once this was done, approximately 20 liters of irrigation were used to clean out the peritoneal cavity and suction out. The proximal colon reached easily the proposed colostomy site without tension. A disk of skin was removed from the colostomy site and the right lower quadrant incision was deepened through all layers of the abdominal wall and dilated to accommodate two of my fingers. Colon was passed out through the ostomy site without torsion or tension. It was tacked to the fascia with 3-0 Vicryl sutures. Two closed suction drains were placed, one in the left upper quadrant and one in the pelvis, and brought through separate stab wound incisions lateral to the incision. These were secured with 3-0 nylon. Attention was then turned to the peritoneal cavity fascial area, where a looped 0-PDS was used to approximate the fascia. The wound then was irrigated copiously with another liter of irrigation and stapled loosely skin edges together. The wound was then packed with Silvercel rope packing and then a silver wound V.A.C. was placed. The colostomy was matured with multiple interrupted sutures of 3-0 Vicryl and the ostomy bag was applied. The patient tolerated the procedure well, and was wheeled to the Post Anesthesia Care Unit in stable condition.