DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Intra-abdominal mesenteric mass.
2. Small bowel obstruction.
3. Small bowel intussusception.
POSTOPERATIVE DIAGNOSES:
1. Small bowel mesenteric mass.
2. Small bowel intussusception.
3. Involvement of mesenteric mass with small and large bowel and omentum.
OPERATIONS PERFORMED:
1. Exploratory laparotomy.
2. Resection of small bowel mesenteric mass with accompanying small bowel resection and partial colectomy for en bloc resection of tumor.
3. Small bowel resection of area of small bowel intussusception.
4. Partial omentectomy.
5. Mobilization of splenic flexure.
6. End colostomy placement.
7. Placement of local anesthetic infusion pump.
8. Placement of adhesion barrier.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
ANESTHESIA: General endotracheal
DESCRIPTION OF OPERATION: After proper consent was obtained, the patient was brought to the operating room and placed on the table in the supine position. General endotracheal anesthesia was administered. The patient had TED hose, SCDs, and Foley catheter placed. The abdomen was prepped and draped in sterile manner.
An incision was made in the midline with a #10 blade. Dissection was carried down with cautery through the subcutaneous tissues and the fascia to the preperitoneal space. The underlying peritoneum was grasped with hemostats and opened sharply. Some acidic fluid was encountered. This was suctioned with pull suction. All layers of the incision were opened under direct vision. Bookwalter retractor was placed. General abdominal exploration was undertaken and revealed evidence of a large tumor mass involving the small bowel mesentery of the proximal ileum that had an area of small bowel encased within the tumor and was partially encasing a portion of sigmoid colon. There was gross disease extending further back into the root of the mesentery, but much less bulky in nature.
Distal in the small bowel, from the area of small bowel involvement in the tumor, there was an area of small bowel involved with intussusception. The small bowel from this point proximal was markedly dilated consistent with small bowel obstruction. There was a lot of stool within the colon concerning for partial colonic obstruction at the level of the sigmoid involvement with the tumor. There was no evidence of any tumor palpable on the liver, gallbladder, spleen, stomach or remaining areas of small and large bowel other than those mentioned above. No evidence of any peritoneal seeding. There was some palpable tumor in the anterior abdominal wall on the right lower abdomen; however, this was not gross tumor invading through the peritoneal space into the abdomen and could not be visualized. The exploration revealed that the tumor appeared to be resectable without hindering blood flow to the rest of the small and large intestine, and therefore, decision was made for en bloc resection of the tumor mass and the encased small and large bowel.
First, the sigmoid colon was mobilized from the left lateral abdominal wall with cautery and traction and countertraction. This dissection continued proximally up to the level of the splenic flexure. The LigaSure device was used as needed for vascular pedicles as the splenic flexure of colon was mobilized. Cautery was also utilized to help mobilize this portion of colon. Once the splenic flexure was completely mobilized as well as the sigmoid and left colon, a GIA 75 mm stapler was used to divide the sigmoid and left colon proximal and distal to the area of involvement with the tumor. This was done by first dissecting a small window in the mesentery of the area of colon to allow for the stapler to be placed directly on colon tissue with no intervening fatty tissue. The mesentery of the colon was then taken down with the LigaSure, and good hemostasis was noted.
Next, the small bowel that was coming into and exiting the tumor mass was transected with GIA 75 mm stapler in similar fashion. The mesentery of that small bowel was taken down as well with a LigaSure. At the base of this area of mesentery, there was thicker mesenteric tissue consistent most likely with metastatic tumor within the mesenteric lymph nodes. The patient did have right colic vessel, which was bleeding despite use of LigaSure at this point, which was easily controlled with forceps and hemoclip and then oversewn with 2-0 silk suture. Complete hemostasis was noted at that area.
The tumor was removed and submitted for permanent pathologic analysis. A functional end-to-end and stable side-to-side anastomosis of the small bowel was performed with GIA 75 mm stapler and TA 60 stapler. The bowel was secured adjacent to each other with interrupted silk sutures to avoid tension on the staple lines. The mesenteric defect was closed with interrupted 3-0 silk sutures. The area of intussusception was resected again with healthy viable-appearing small bowel with good gross margins proximal and distal, as we did with the tumor. The same sort of anastomosis was done in a similar manner. Mesentery was closed again with interrupted silk sutures. At this point, final inspection of the abdomen revealed all operative areas to be hemostatic.
The anastomoses were intact with no tension and no evidence of any hematomas or ischemia or discoloration. Viscous skin and underlying subcutaneous tissue was excised using cautery from the left upper abdominal wall region over the rectus muscle, and the underlying fascia anteriorly was opened in a cruciate manner with cautery. The underlying rectus fibers were split parallel to their fibers and the posterior fascia and peritoneum was opened. Babcock was used to then pull the left colon through this opening and the colon secured to the posterior and anterior fascia with multiple interrupted 3-0 silk sutures. This bowel had viable appearance. The bowel was noted to be full of firm hard stool.
The patient did have some omentum that had been adherent to the tumor, and because of some discoloration and concern of tumor within the omentum, that portion of the omentum was resected using the LigaSure device resecting approximally one third to one half of this patient’s omentum in that manner. This was submitted for permanent pathologic diagnosis as well. After irrigation of the abdomen, the final inspection revealed complete hemostasis, and all areas of bowel resection appeared to be intact with healthy viable tissue.
Multiple sheets of Seprafilm were then placed around the colostomy internally where it passed through the posterior fascia. Also, Seprafilm was placed over the distal sigmoid colon where the colon resection had occurred internally. Seprafilm was then further placed throughout the pelvis, right and left gutters and then interspersed between multiple loops of small bowel and then along the anterior abdominal viscera. The midline fascia was then closed with running loop #1 PDS suture starting at each end and tying suture in the middle. Palpation revealed good closure.
Two On-Q pain pump catheters were then brought through small percutaneous access points in the right upper quadrant of the abdomen, and these catheters were brought in through the incision superiorly and positioned such that they would irrigate local anesthetic along the fascia, along the entire length of the incision. These catheters were secured to the skin with benzoin and Steri-Strips. The subcutaneous tissue was closed with a running 2-0 Vicryl suture on top of the pain pump catheters. The skin was then closed with staples. The colostomy was then matured by excising a staple line at the end of the colon with cautery. There was some firm stool, which was removed, and the colonic mucosa was noted to be pink and viable with no evidence of ischemia or hematoma.
The colostomy was matured with interrupted 3-0 Vicryl sutures placed at the dermis level and then proximally on the bowel wall with a seromuscular bite and then at the end of the colon segment to perform a rosebud fashion-type colostomy. The patient had a colostomy appliance placed and dry dressing placed on the midline incision. The patient had anesthesia reversed and was taken to the recovery room postoperatively.
