DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Rectal cancer.
POSTOPERATIVE DIAGNOSIS: Rectal cancer.
OPERATION PERFORMED: Total proctocolectomy with end ileostomy, abdominal and perineal approach.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
DRAINS: #10 JP x1.
TUBES: None.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 700 mL.
POSTOPERATIVE CONDITION: Stable.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who is status post right hemicolectomy in the past for a T3N0 lesion. The patient now presents with a new to metachronous rectal cancer, which is about 5 cm up from the anal verge, and on preoperative ultrasound, this is a T3N1 lesion. The patient is status post neoadjuvant chemotherapy and now presents for completion colectomy with proctectomy and likely a complete proctectomy with an end ileostomy.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and laid on the table in the supine position. Following adequate induction of general endotracheal anesthesia, Foley catheter was placed and then the patient was placed in the lithotomy position in stirrups. The rectum was irrigated, and rectal examination was performed. The scar of the tumor was palpable about 5 cm up from the anal verge or maybe even 4 cm.
At this point in time, rectal irrigation was performed with Betadine and saline. The abdomen and perineum were then prepped and draped in the usual fashion. Following this, a midline incision was made, and the peritoneal cavity was entered. Some adhesions were taken down from the previous operation. Following this, the Bookwalter retractor was placed for exposure. The transverse colon, the terminal ileum, and the previous anastomosis were completely mobilized. The splenic flexure was taken down, the omentum was completely resected, and then the descending colon and sigmoid colon were completely mobilized at the white line of Toldt as well. The bilateral ureters were identified and carefully protected throughout the course of the dissection.
Following this, the terminal ileum was divided using a 75 blue load of a GIA stapler and then the LigaSure was used to take down the mesentery of the transverse colon, the splenic flexure and descending colon down towards the sigmoid colon. High ligation of the IMA was performed taking the vessel near its takeoff with the LigaSure and then sharp total mesorectal excision was performed using electrocautery dissection, dissecting posterior to the rectum and extending our dissection below the level of the tumor all the way down to the levator muscles. The lateral stalks were taken down using the cautery as well.
The anterior dissection was difficult due to the anterior location of the tumor, and there was some scar tissue between the tumor and near the bladder. We were able to get into a good plane free of tumor between the rectum and the bladder and carried this dissection distally down to the level of the levators. Grossly, the tissue left on the bladder anteriorly and the anterior structures was soft and normal tissue and devoid of any gross tumor. The tumor was very low in the pelvis, and despite carrying the dissection all the way down to the level of the levators, it was not possible to put a stapling device below the tumor and to get an adequate 2 cm margin as the tumor extended right down to the level of the levators.
Therefore, we proceeded with an abdominal perineal resection of the rectum, and the rectum was completely resected through a perineal approach taking the rectum in its entirety and delivering it up into the peritoneal cavity to remove the specimen. The entire specimen consisted of the terminal ileum, previous anastomosis, the remainder of the abdominal colon and the entire rectum as well as the omentum.
The rectum was opened on the back table later in the case. The scar and the residual tumor were visualized, and there was good margins grossly all around the tumor. There was no residual disease that was grossly palpable or visible within the pelvis following the resection. Irrigation was performed and suctioned out. The peritoneum was closed in layers with 2-0 Vicryl popoff sutures in the levator and then another two layers of 2-0 Vicryl popoff sutures in the more superficial layers followed by a running 4-0 Monocryl subcuticular stitch in the skin and Dermabond to the skin.
The terminal ileum was mobilized and brought out through a separate ostomy opening in the right side of the abdomen in the previously marked spot in the abdominal wall. This came easily through the abdominal wall with no tension whatsoever, and it was well vascularized. The small bowel was placed back into the abdomen in gentle S-shaped curves, and a #10 JP drain was placed through separate stab incision in the left lower quadrant and placed into the pelvis.
Following this, the fascia was closed with looped #1 PDS suture starting at the top and bottom and tying in the middle. Subcutaneous tissue was irrigated and skin was closed using staples. Dry dressing and Tegaderm and silk tape were applied for the dressing. Following this, the ileostomy was matured with 3-0 Vicryl popoff sutures maturing it in a Brooke fashion, and it looked pink and viable. An ostomy appliance was placed and the procedure was ended, and the patient tolerated the procedure well.
