Multiple Abdominal Surgeries. Don't want to miss anything.

ksb0211

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Deltona, FL
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This patient had mutliple surgeries and I'm hoping for some backup and I don't want to miss out on anything. Thank you so much for any input.

DATE OF SURGERY
02/15/2012
PREOPERATIVE DIAGNOSIS
Obstructing lesion of the colon, rule out neoplasm, rule out diverticulitis.
POSTOPERATIVE DIAGNOSIS
Obstructing lesion of the colon, diverticulitis.
OPERATION PERFORMED
1. Sigmoid resection with end-to-side EEA anastomosis.
2. Decompression of bowel.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room. After the attainment of sufficient general anesthesia he was pretreated with antibiotics and prepped and draped in the usual sterile fashion. Our plan was going to be to do this laparoscopically, but the patient's morbid obesity precluded our ability to get him onto our operating table with the beanbag to hold him in place and also still be able to use a Bookwalter retractor when that would become necessary late in the case. For this reason we elected to go with the purely open approach, although it was a secondary concern, it was obviously the best choice for this particular patient and his body habitus. We prepped and draped in the usual sterile fashion, made an incision extending from the pubis to just above the umbilicus. We exposed the abdominal contents and then using the Bookwalter put on the foot of the bed, because again, the patient is so obese we could not get the Bookwalter up to the top of the table because his abdomen was taller than the Bookwalter. We moved the Bookwalter down to the lower portion of the bed, we were able to get the Bookwalter into position. We then identified that the colon was absolutely plastered up against the bladder. We removed this area and then fired a stapler distally and then took down the mesocolon, both with 2-0 silk ties and with the Harmonic scalpel. Once we had dissected up we realized we had enough length to come down and fired through the barrel of the colon to make a side of proximal colon to end of the distal colon anastomosis with a 28 mm CEA. We did open the bowel, which was obstructed, and decompressed the patient. We did have a minimal amount of spillage, but we were set up with two suctions to handle it and we handled it immediately and went ahead and irrigated copiously after we did give our bit of spillage; again, the spillage was relatively limited. Went ahead and we clamped off the bowel after we had pretty much decompressed it, and then sized out the distal bowel to 28 mm, placed an anvil into position after firing a pursestring and then went down the barrel of the sigmoid colon in a retrograde fashion and then coming out the side of the descending colon brought out the sharpened obturator and made our anastomosis of the side of the descending colon to the end of the sigmoid making a 28 mm anastomosis. We then used CTA 60 to close the rent in then air tested the anastomosis by putting a clamp distally Finding out it was dry, but we elected to reinforce all of this anastomosis with 3-0 silks placed in a Lembert fashion and also the TA suture line was reinforced and covered with surrounding epiploic fat. We irrigated copiously and then placed a drain into the pelvis, looked at the dome of the bladder and felt that there was no obvious perforation in this area, although there was an abscess there. We did take cultures of that abscess at the beginning of the operation. We elected to irrigate once again with a liter of antibiotic-containing solution, we used several liters of antibiotic-containing solution as irrigant in the course of this procedure. Once that was done, we went ahead and turned our attention to closure. We closed with double stranded #1 PDS followed by irrigation of the wound. Given the patient's obesity, we placed a drain into the wound, this was a 10 mm Jackson-Pratt placed via stab wound. Then, closed with deep sutures of 3-0 Vicryl, then with skin staples after following irrigation. Drains were secured with 3-0 nylon. We then placed sterile dressings. The patient tolerated the procedure well.

DATE OF SURGERY
02/20/2012
PREOPERATIVE DIAGNOSIS
Presumptive peritonitis with anastomotic leak, sepsis.
POSTOPERATIVE DIAGNOSIS
Anastomotic breakdown with diffuse peritonitis.
PROCEDURE
Exploratory laparotomy with takedown a previous anastomosis and diverting loop colostomy and abdominal lavage with small bowel decompression.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room. After attainment of sufficient general anesthesia, he was pretreated with antibiotics and prepped and draped in the usual sterile fashion. Opened up the previous incision and entered the abdominal wound and the abdominal wound looked kind of feted and thought maybe this is where his sepsis was coming from, but that that was not proved to be the case. I opened up of the incision, got in the abdomen, there was frank stool present in the left lower quadrant and a lot of peritoneal fibrinous materia. I put a clamp on the descending colon, stopped the leak of stool, irrigated and then switched over to a propulsion irrigator and at this point, just aspirated the fluid and at this point we just saw that this patient had very diffuse peritonitis which was widespread. His bowel was distended. We realized in order to get a visualization in this morbidly obese gentleman of the operative site remained the decompresses bowel. So with our clamp in place with stool leakage actually stopped we cleaned up things, initially, but then decompressed the small bowel back within the abdominal cavity betting about 2000 mL of sulcus entericus, but this afforded us an opportunity to; 1, run the bowel, but also to get enough visualization that we could see what was going on. Once we did that, we irrigated anything that we could see, we used several liters of fluid initially. Ultimately we would use almost 2 gallons of irrigant on this patient, all of which was containing antibiotics. We were able to pack the small bowel away see that it looked like our anastomosis had broken down between the area that we had introduced the stapler and down at the anastomosis itself. Our previous reinforcing sutures were in evidence but we fired a GIA proximally at the distal colon and then 1 distally over the site remains of the sigmoid and then took down the mesentery and then removed the anastomosis. We irrigated at this point this portion of the operative field. Went down into the pelvis, irrigated with the propulsion irrigator then came back in a very systematic fashion twice. We irrigated all the small bowel loops, taking off as much of fibrinous material was as we could get off easily and then make sure any particulate matter was removed. Then the last above the liver with the propulsion irrigator, used our hand as well and a lap pad to abrade the area then re-propulsion irrigated, when up in the left upper quadrant and did the same thing. I then went back into the left gutter where there was a lot of fibrous material washed that up, and again with a lap pad just sort of abraded and then after we had abraded and irrigated, we went back and irrigated once again. We placed a 10 mm Jackson-Pratt in the operative site, realizing that abdominal drainage was not going to be possible with the extent of peritonitis which was involved and then extended our incision in order to get this patient colostomy. The patient is quite obese and we were able to get the mid transverse colon mobilized. We took down the omentum to afford us access. Placed a Kelly clamp to in over the antimesenteric portion of the transverse colon and with some effort, pulled up enough of the colon and taken get above the skin level and then initially, we placed a figure-of-8 suture of #1 PDS up there and it just did not look right. We took it down and then put our stitches little bit lower, then worked our suture line back up to the colon, keeping the colon on tension so we could keep above the skin surface. At this point, we elected to close remainder of the wounds and we had carefully reordered the small bowel back within the abdominal cavity, covered with omentum and then closed with figure-of-8 sutures of #1 PDS placed in multiple levels. The patient was hypotensive pretty much throughout the case, septic and what we elected to do was to just not to mature the colostomy on the table. We thought that would afford us to 2 opportunities, 1 our plan was to bring him back for subsequent washouts, but also this way we would not have a hole in the colon that we would have after contend with during the next operative procedure and so we fixed the colon in place at that level, then irrigated the wound once again and then used widely spaced skin staples and some interrupted nylons up at the colostomy site. He tolerated the procedure poorly. His overall prognosis is in some question.

DATE OF SURGERY
02/22/2012
PREOPERATIVE DIAGNOSIS
Sepsis, diffuse peritonitis.
POSTOPERATIVE DIAGNOSIS
Sepsis, diffuse peritonitis.
OPERATION PERFORMED
Exploratory laparotomy with abdominal lavage.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room after attainment of sufficient general anesthesia, he was pretreated with antibiotics and prepped and draped in the usual sterile fashion. Removed the sleeve staples and sutures, we prepped him at that point. Opened the abdomen, went back in and the abdomen looked remarkably better than it did from the other night. We irrigated. We actually use propulsion irrigation and used probably a total of about 6 L of fluid with antibiotic containing solution irrigating all quadrants of the abdomen, running the small bowel in its entirety, going into the retroperitoneum and just washing everything once again. This patient still is desperately ill, but nevertheless his abdominal contents looked just remarkably better over the last 36 hours. I was quite pleased at what I saw and the remarkable in _____ toward improvement which we noted. Once I washed everything out, there really was not much to do in the way of operation. Replaced everything and then closed with retention sutures this time and then interrupted sutures of #1 PDS. We very broadly just a few clips in the skin to approximate it to allow ready drainage. I think we used about 3 clips in a relatively long incision. Once that was done, we placed a sterile dressing. We did nick the colostomy, which we did not take down during the course of this procedure. We nicked it just to let gas out and the plan would be to mature it at a later date. The patient tolerated the procedure actually quite well. He was hemodynamically stable throughout.
 
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