Wiki Exploratory laparotomy with takedown of mesh closure of a colon wall injury or colotomy and evacuation of intraabdominal abscess

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NAME OF OPERATION OR PROCEDURE: Exploratory laparotomy with takedown of mesh closure of a colon wall injury or colotomy and evacuation of intraabdominal abscess.

INDICATIONS FOR PROCEDURE: This is a 64-year-old white female, who underwent takedown of incarcerated incisional hernia on 05/14/2021. She has developed abdominal pain, abdominal wall abscess, and clear evidence for infection at the local site. We proceed now for exploration.

DESCRIPTION OF PROCEDURE: The patient was administered adequate general endotracheal anesthesia, prepped and draped in sterile fashion. We first attempted to place a trocar at distant site in the upper abdomen away from the prior surgery. We did not have success with this and after attempt only a Veress needle was placed and removed. We proceeded to open the abdomen through the old incision in the midline. We opened this up and entered into the hernia sac. The hernia sac had some purulence present. We took cultures and sent these for review. We continue to open this up and down to the fascia itself. The mesh was completely intact and stapled in place. I was able to push my finger down and placed it between the mesh in the abdominal wall. I slowly and methodically lifted the mesh off the abdominal wall while removing it with its absorbable tacks. We were able to remove this in its entirety and it did have some bilious purulence on it. With the enlarged midline incision, the colon was immediately underneath the center of this incision. The colon was surrounded and covered by omentum. The colon itself was not immediately visible, but the omentum was. I was able to see the site where the hernia reduction was made because this was done by some cautery. I was able to mobilize this more thoroughly and after taking down the omentum off this area of transverse colon, it became evident that there was a small thermal injury to the colon wall itself. The colon wall has an opening of 3-4 mm and this was apparently obscured by the very large area of omentum overlying it at the time of hernia takedown and reduction. In retrospect, this was a perfect course of thermal injury with delayed perforation and symptoms approximately 7 days after initial operation. In any event, I was able to clear away all of the omentum off this colotomy injury and we exposed what appeared to be a 3 to 4 mm opening in the colon wall, which was somewhat ruddy in appearance. I examined the remainder of the colon and all of the available bowel around it up to the contaminated margins. There was no other injury and the colon tissue around the opening was completely viable. I elected at this time to use multiple 3-0 Vicryl sutures to bring the edges together and then I placed a TA-60 stapling device just beneath these sutures and fired this across the colon wall and completely viable and normal colon tissue to close the colotomy. This tiny area of colon wall was removed and sent for histologic review. At this time, I was completely satisfied that the injury had been found and completely treated. There did not appear to be any other injuries whatsoever and we did inspect immediately under our prior Veress needle site and found no evidence for bowel injury there either. After using 2-3 L of warm saline to wash out the abdomen thoroughly, I placed multiple drains in multiple sites in order to ensure draining from the intraabdominal infection. Because of the contamination, it was not appropriate to bring in more mesh and therefore we closed the midline fascial opening with multiple #1 Vicryl figure-of-eight sutures. They were spaced appropriately 0.75 cm to 1 cm apart and a very tight thorough closure was made. I should note that prior to placement of the sutures I also used the retention sutures with a very large needle, which were present in the OR for retention suture use. Approximately 4 to 5 retention sutures were placed widely 3 cm to 4 cm on each side of the midline wound and brought along the plane between the peritoneum and the fascia underneath. After the midline fascia was closed with the retention sutures in place, we thoroughly irrigated the midline wound and I packed the wound with Betadine-soaked gauze. The retention sutures were taped to the skin with Steri-Strips with plans to return in approximately three days for delayed primary closure of the wound and then placement of retention bridges for support. The wounds were dressed. The drains were charged. The patient was then awakened, taken to Recovery in stable condition having tolerated her procedure well.
 
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