MEZIESKY
Guru
Help please. I have no idea on this one.
Patient remained in modified lithotomy position. Her abdomen and perineum were prepped and draped in sterile fashion. After local infiltration, a supraumbilical incision made, pneumoperitoneum achieved with a Veress. A 12 mm bladeless trocar was then inserted. Under direct vision, a right lateral 5 mm port was placed, and then a site was selected for the Gelport in the left lower abdomen. An incision was made in a muscle sparing manner in the left lower quadrant, approximately 7 cm, carried down through all layers with cautery. Peritoneum was elevated and incised. This was extended with cautery. The inner flange of the Gelport was secured, and then the Gelport was fastened in the usual manner. With lubricated, nondominant hand within the wound, the abdomen was explored. The liver was obviously cirrhotic, and photodocumentation was obtained. Distally, the sigmoid was matted against the left pelvic brim. A plane was then found at the pelvic brim distally, and then what appeared to be a small fistulous connection was divided with Harmonic scalpel at the left vaginal fornix.
Attention then turned towards mobilizing the sigmoid and left colon, but prior to any mobilization outside of the pelvis, what initially was thought to be bowel turned out to be large varicosities. On close inspection, the entire inferior mesenteric vein and most of its tributaries were markedly dilated. Photo documentation was obtained of this as well. There was not enough redundancy in the distal aspect of the sigmoid to safely perform even a sleeve resection without risk of having a foreshortened area that would require mobilization and potentially violating these varicosities. Two of my surgical partners were summoned in the room, and after discussion regarding the situation with the varicosities and potential problem with mobilization which could lead to extensive bleeding and/or worse, decision was made to perform a minimalistic procedure compared to what was anticipated by performing an omental interposition of the areas in question between the colon and the vagina.
Prior to this, dilute Betadine was injected in the vagina and in the rectum, and no evidence of a leak was appreciated. The omentum easily reached the depth of the pelvis. It was circumferentially wrapped around the rectosigmoid, and then tethered with a 2-0 Vicryl to the posterior fornix to act as an interposition between the areas. There appeared to be no ongoing bleeding from the areas of varicosity. A JP drain was introduced through the 12 mm site and brought out through the right lateral 5 mm site. The tip of the drain rested in the pelvis on top of the omental buttress. This was secured to the skin with 2-0 nylon. All ports were now removed under direct vision and the abdomen desufflated. The fascia then likewise closed with figure-of-eight 0 Vicryl. The Gelport site was closed with a running 0 Vicryl for the peritoneum and posterior sheath, and a running 0 loop PDS for the anterior fascia. The skin at this site was closed with staples. The umbilical site was closed with subcuticular 4-0 Monocryl. Patient tolerated the procedure well. There were no complications. She was then extubated and taken to recovery in satisfactory condition
Patient remained in modified lithotomy position. Her abdomen and perineum were prepped and draped in sterile fashion. After local infiltration, a supraumbilical incision made, pneumoperitoneum achieved with a Veress. A 12 mm bladeless trocar was then inserted. Under direct vision, a right lateral 5 mm port was placed, and then a site was selected for the Gelport in the left lower abdomen. An incision was made in a muscle sparing manner in the left lower quadrant, approximately 7 cm, carried down through all layers with cautery. Peritoneum was elevated and incised. This was extended with cautery. The inner flange of the Gelport was secured, and then the Gelport was fastened in the usual manner. With lubricated, nondominant hand within the wound, the abdomen was explored. The liver was obviously cirrhotic, and photodocumentation was obtained. Distally, the sigmoid was matted against the left pelvic brim. A plane was then found at the pelvic brim distally, and then what appeared to be a small fistulous connection was divided with Harmonic scalpel at the left vaginal fornix.
Attention then turned towards mobilizing the sigmoid and left colon, but prior to any mobilization outside of the pelvis, what initially was thought to be bowel turned out to be large varicosities. On close inspection, the entire inferior mesenteric vein and most of its tributaries were markedly dilated. Photo documentation was obtained of this as well. There was not enough redundancy in the distal aspect of the sigmoid to safely perform even a sleeve resection without risk of having a foreshortened area that would require mobilization and potentially violating these varicosities. Two of my surgical partners were summoned in the room, and after discussion regarding the situation with the varicosities and potential problem with mobilization which could lead to extensive bleeding and/or worse, decision was made to perform a minimalistic procedure compared to what was anticipated by performing an omental interposition of the areas in question between the colon and the vagina.
Prior to this, dilute Betadine was injected in the vagina and in the rectum, and no evidence of a leak was appreciated. The omentum easily reached the depth of the pelvis. It was circumferentially wrapped around the rectosigmoid, and then tethered with a 2-0 Vicryl to the posterior fornix to act as an interposition between the areas. There appeared to be no ongoing bleeding from the areas of varicosity. A JP drain was introduced through the 12 mm site and brought out through the right lateral 5 mm site. The tip of the drain rested in the pelvis on top of the omental buttress. This was secured to the skin with 2-0 nylon. All ports were now removed under direct vision and the abdomen desufflated. The fascia then likewise closed with figure-of-eight 0 Vicryl. The Gelport site was closed with a running 0 Vicryl for the peritoneum and posterior sheath, and a running 0 loop PDS for the anterior fascia. The skin at this site was closed with staples. The umbilical site was closed with subcuticular 4-0 Monocryl. Patient tolerated the procedure well. There were no complications. She was then extubated and taken to recovery in satisfactory condition