herrera4
Guru
im having trouble with the 'biopsy of bladder' portion of this note-any help is appreciated
DETAILS OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. Following the induction of general anesthesia, placement of bilateral lighted ureteral stents. After a timeout, sigmoidoscopy was attempted after digital rectal examination. Digital rectal examination documented a very tight narrowing of the rectum that would allow passage of the tip of my finger. This was located at probably 7 cm; the sigmoidoscope was inserted. Visualization was good but again I was unable to advance the scope past the obstruction. I then scrubbed. The patient was then prepped in the usual sterile fashion using ChloraPrep. After appropriate timeout, the abdomen was entered through a small curvilinear incision in the superior aspect of the umbilicus, under direct visualization without injury to the underlying viscera. A 5 mm port was inserted. A 5 mm 30 degree laparoscope was inserted after establishment of pneumoperitoneum. The abdomen was explored; there was no evidence of gross metastatic disease within the pelvis. Additional ports were placed in the right lower quadrant and right mid abdomen under direct visualization. The 5 mm port was then changed to a 12 mm port at the umbilicus. Using two-handed dissection, the small bowel was maneuvered out of the pelvis. Peritoneal fluid was sampled using a red rubber catheter and sent for cytology. Next, the peritoneum overlying the very thickened bladder posteriorly on the right was incised with a LigaSure device. Using cautery scissors, representative samples of the bladder tumor were taken. Next, the colon was mobilized from the pelvic brim to the mid-descending colon to allow for a tension-free sigmoid colostomy. A decision was made to perform a loop sigmoid colostomy due to concern for distal obstruction and obstruction of the distal segment of the rectum. Once the colon was mobilized, the previous point of colostomy was incised after injection of local anesthetic with transverse orientation. This was carried down through the skin and subcutaneous tissue. Rectus sheath was incised; the rectus muscle was partially divided. The 12 mm port was then inserted through the incision and a grasper was used to grasp the mobilized sigmoid loop. Pneumoperitoneum was evacuated. The incision was enlarged to allow delivery of the sigmoid colon loop to the skin surface. The incisions were then closed using Vicryl 0 for the fascia followed by 4-0 Vicryl to the skin.
Next, the ostomy appliance was applied after partially closing the fascia using Vicryl sutures and partially closing the skin using Vicryl sutures. This fit nicely over the colon. The colostomy bridge was then placed and the colostomy was matured with multiple sutures of 3-0 Vicryl.
DETAILS OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. Following the induction of general anesthesia, placement of bilateral lighted ureteral stents. After a timeout, sigmoidoscopy was attempted after digital rectal examination. Digital rectal examination documented a very tight narrowing of the rectum that would allow passage of the tip of my finger. This was located at probably 7 cm; the sigmoidoscope was inserted. Visualization was good but again I was unable to advance the scope past the obstruction. I then scrubbed. The patient was then prepped in the usual sterile fashion using ChloraPrep. After appropriate timeout, the abdomen was entered through a small curvilinear incision in the superior aspect of the umbilicus, under direct visualization without injury to the underlying viscera. A 5 mm port was inserted. A 5 mm 30 degree laparoscope was inserted after establishment of pneumoperitoneum. The abdomen was explored; there was no evidence of gross metastatic disease within the pelvis. Additional ports were placed in the right lower quadrant and right mid abdomen under direct visualization. The 5 mm port was then changed to a 12 mm port at the umbilicus. Using two-handed dissection, the small bowel was maneuvered out of the pelvis. Peritoneal fluid was sampled using a red rubber catheter and sent for cytology. Next, the peritoneum overlying the very thickened bladder posteriorly on the right was incised with a LigaSure device. Using cautery scissors, representative samples of the bladder tumor were taken. Next, the colon was mobilized from the pelvic brim to the mid-descending colon to allow for a tension-free sigmoid colostomy. A decision was made to perform a loop sigmoid colostomy due to concern for distal obstruction and obstruction of the distal segment of the rectum. Once the colon was mobilized, the previous point of colostomy was incised after injection of local anesthetic with transverse orientation. This was carried down through the skin and subcutaneous tissue. Rectus sheath was incised; the rectus muscle was partially divided. The 12 mm port was then inserted through the incision and a grasper was used to grasp the mobilized sigmoid loop. Pneumoperitoneum was evacuated. The incision was enlarged to allow delivery of the sigmoid colon loop to the skin surface. The incisions were then closed using Vicryl 0 for the fascia followed by 4-0 Vicryl to the skin.
Next, the ostomy appliance was applied after partially closing the fascia using Vicryl sutures and partially closing the skin using Vicryl sutures. This fit nicely over the colon. The colostomy bridge was then placed and the colostomy was matured with multiple sutures of 3-0 Vicryl.