Lap sigmoid colectomy & lap right colectomy

nlbarnes

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Escondido, CA
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44207 & 44202?

We started with the sigmoid colon. The patient has a very
fatty, heavy mesentery. He also has quite a fatty retroperitoneum. The white
line of Toldt on the left side was taken down with a combination of the
scissors without cautery and the #5 EnSeal. These two instruments were used
in this fashion for the entire intracorporeal portion of the dissection. We
spent a great deal of time looking for the ureter on the left side as again
there was extensive thick somewhat sticky retroperitoneal fat. This fat was
distant from the cancer, but bled easily and was challenging to work with.
Eventually, we did identify and preserve the left ureter and ensured that it
was off lateral away from where the remainder of the surgery would be. We
also followed it into the pelvis and insured it was lateral to where we opened
the peritoneum all the way down into the pelvis. The pelvis was relatively
narrow. We opened the pelvic peritoneum all the way around with a #5 EnSeal
to make sure that we would have a better ability to get the EEA stapler up to
the rectosigmoid junction. The colon cancer was in the mid to distal sigmoid
colon. We took down the white line of Toldt up to the splenic flexure, but we
did not take down the splenic flexure. We opened the plane between the left
kidney and the caudal aspect of the descending colon mesentery. We then
opened the peritoneum to the sigmoid mesentery at its base on the patient's
right hand side. Care was taken to avoid injury to the right ureter. We
opened this peritoneum all the way down into the pelvis and then up across the
inferior mesenteric artery pedicle. We opened the hole in the mesentery
proximal to the takeoff of the inferior mesenteric artery from the aorta. We
actually visualized the left colic branch and I divided that between large
hemoclips with two large hemoclips on each side and then divided with
scissors. We then divided the inferior mesenteric artery at its origin with
the Endo-GIA 60 white 2.5 mm stapler, taking care to avoid injury to the left
ureter. The staple line was reinforced as per my habit with large hemoclips.
We then chose the distal resection line to be at the rectosigmoid junction.
This was at least 5 cm distal to where the ink that was placed distal to the
cancer in the sigmoid colon. We divided the mesentery to the rectosigmoid
junction with the #5 EnSeal and then we divided the rectosigmoid
junction with the Endo-GIA 60 blue 3.5 mm reticulating stapler in a
single pass. We then made a small upper midline incision, placed the
Alexis wound protector and attempted to extrude the specimen. Between
the heavy thick mesentery and the size of the cancer itself, I was not
able to get this cancer out of an Alexis port and therefore, I made
the incision a little bit larger and converted to a hand port, and
with that and using my hand, we were just able to get the cancer out
through the lumen of the hand GelPort. We then divided the mesentery
to the descending colon between Mayo clamps, ligating with 2-0 silk
suture just proximal to the IMA staple line. We then divided the
bowel in the distal descending colon with automatic pursestring device
and placed a #28 blue 3.5 mm Covidien EEA anvil. The bowel was
cleaned off as per my habit with the electrocautery and then we placed
a second 3-0 Prolene pursestring as per my habit and also because
there were couple of diverticula at the point of division and we drew
these into the donut with the pursestring suture. Then, we had an
excellent surface for the EEA to fire on. The bowel appeared pink and
healthy and its edges were bleeding, which we cauterized. We dropped
the bowel back into the abdomen and replaced the top of the GelPort
and then dropped the anvil down into the pelvis and there did look
like there would be excellent length. We did have to take a little
omentum off the descending colon, which we did with a #5 EnSeal to
gain this length. We then performed a #28 Covidien blue 3.5 mm EEA
anastomosis. Care was taken to avoid twisting in the mesentery. Both
donuts were excellent. The anastomosis was insufflated under saline,
clamping off the proximal side and there was no evidence of leak. The
anastomosis on rigid sigmoidoscopy was 15 cm from the anal verge.
Both sides of the anastomosis appeared pink and healthy on rigid
sigmoidoscopy, and the anastomosis appeared intact. We then turned
our attention to performing the right colectomy. The white line of
Toldt on the patient's right side was taken down. The duodenum was
identified and preserved. The gastrocolic omentum was divided with a
#5 EnSeal and the duodenum again was identified from this aspect, and we
opened the plane between the caudal aspect of the right colon mesentery and
the kidney on the right side and elevated the bowel superiorly. We then
holding the bowel up, identified the hole in the mesentery distal to the
takeoff of the ileocolic artery and opened that with a #5 EnSeal, and then we
opened the hole in the mesentery proximal to the takeoff of the ileocolic
artery with a #5 EnSeal and then we divided the ileocolic artery at its base
with the Endo- GIA 60 white 2.5 mm stapler, taking care to avoid injury to the
duodenum, and our artery division was even with the level of the duodenum. The
staple line was reinforced as per my habit with large hemoclips. We took down
enough of the gastrocolic omentum, so that we would be able to extrude the
proximal transverse colon and then we extruded the right colectomy specimen
through the hand GelPort. We divided the mesentery to the terminal ileum
between Mayo clamps, ligating with 2-0 silk suture and then we divided the
mesentery to the proximal transverse colon between Mayo clamps, ligating with
2-0 silk suture and then we divided the terminal ilium and the proximal
transverse colon each with a GIA 75 blue stapler. We then performed a
functional end-to-end anastomosis with a GIA 75 blue stapler for the long axis
and closing the holes for the stapler with interrupted 3-0 silk suture for the
outer layer and running 3-0 Vicryl suture for the inner layer. Hemostasis
along the staple lines appeared excellent overall. We did place one 3-0 silk
suture at the transverse staple line on the small bowel and we placed a 3- 0
silk heel stitch. Again, the bowel appeared pink and healthy on both sides of
 
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