Open near total proctocolectomy (44155-52) and ileostomy with omental J (44700-22)

nlbarnes

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44155-52 & 44700-22? Would appreciate feedback please.

I dissected the large tumor mass away from the pelvic sidewalls
in the total mesorectal excision plane, and then was able to come around the
anterior aspect though I was quite close to the seminal vesicles particularly
on the patient's right, but I was able to separate the cancer mass from the
anterior tissues and the pelvic sidewalls in a grossly clean plane. Once I
knew this was possible, I then went and divided the inferior mesenteric artery
at its base doubly ligating proximally, singly ligating distally with 0 silk
suture. I divided the mesentery to the sigmoid descending colon junction
between mayo clamps, ligated with 2-0 silk suture and then divided the colon
at that point with a GIA 60 blue stapler. I needed to divide the colon to
facilitate visualization into the pelvis to complete the removal of the
rectal cancer. I then dissected all the way down the presacral space to the
levators with the cautery and lifted up the large rectal cancer, which really
was proceeding into the distal sigmoid colon as well. I cleaned off the
mesentery just proximal to the levators using monster clamps and tying with 2-
0 silk suture and then I considered how best to divide the rectum. This was
quite a large patient and his rectum in fact was also quite large and thick
feeling although much softer than where the cancer was more proximally. The patient
did have a relatively wide pelvis for a male and so I got a TA 60 green 4.5 mm
stapler and used that to divide the rectum and that went quite nicely. The
stapler clamped down easily on the rectum and we divided it and sent the
rectosigmoid off the field. To try to minimize the risk of rectal stump blow
out, I over sewed the staple line with interrupted 2- 0 silk Lembert sutures
taking quite large bites and folding the staple line in. We then irrigated
the pelvis with normal saline. Hemostasis was checked and there was a little
bit of oozing, so we placed some FloSeal and placed a couple of lap pads and
then turned our attention to the colon. The white line of Toldt on the
patient's right side was taken down.
The hepatic flexure attachments were taken down between Mayo clamps, ligating
with 2-0 silk suture. The omentum was dissected off the transverse colon. It
was in some places fused to the transverse colon mesentery, but we tried to
preserve as much of it as possible. We identified and preserved the duodenum.
We also identified and preserved both ureters repeatedly during the case. We
then divided the mesentery to the proximal transverse colon between Mayo
clamps, ligating doubly and proximally as needed with 0 silk suture. I also
divided the ileocolic artery not at its base, but in the middle between
monster clamps and doubly ligated proximally with 0 silk suture and singly
ligated distally with 0 silk suture. We then took down the rest of the white
line of Toldt on the patient's left side and then took down the splenic
flexure taking care to avoid injury to the spleen. We then took down all the
remaining mesenteric attachments to the distal transverse colon descending
colon in the same fashion between Mayo clamps, ligating singly and doubly as
needed with 0 silk suture. We then took a look at the terminal ileum and
decided that the best place to divide it would be about 10 cm proximal to the
ileocecal valve where there was minimal carcinomatosis on the bowel itself.
so we then divided the mesentery to this site on the
terminal ileum between Mayo clamps, ligating with 2-0 silk suture and divided
the bowel with a GIA 75 blue stapler. We then took the
omentum and checked it for ischemia and only the very end was ischemic, we
divided that over a Mayo clamp and ligated that with 2-0 silk suture and then
we placed the omentum down the left retroperitoneum, taking care to avoid any
twisting, and dropped it into the pelvis. It did not quite fill the pelvis,
but it is certainly partly filled the pelvis and covered the sacral bones
nicely.
 
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