Wiki Partial Colectomy, partial gastrectomy, PEG placement, Gastrocolic cutaneous fistula

encameron12

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PREOPERATIVE DIAGNOSES: Gastrocolic cutaneous fistula with exposed infected hernia mesh.

POSTOPERATIVE DIAGNOSIS: Gastrocolic cutaneous fistula with exposed infected hernia mesh.

NAME OF PROCEDURE:
1. Excision of exposed and infected herniorrhaphy mesh.
2. Partial transverse colectomy with adherent mesh and fistula tract.
3. Partial gastrectomy of adherent hernia mesh and fistula tract.
4. Gastrostomy tube placement with use of percutaneous gastrostomy kit.
5. Side-to-side 80 millimeter GIA colocolostomy anastomosis.
6. Complex abdominal wall closure with posterior Strattice underlay mesh.
7. Placement of small sponge wound VAC to the lower half of abdominal incision.

INDICATIONS: An 89-year-old with a draining fistula tract in the mid abdomen over her prior hernia repair. She was referred for excision.

FINDINGS: The patient had an adherent ventral hernia mesh erosion into the transverse colon as well as the stomach. The mesh was excised in its entirety and resection of the adherent transverse colon and stomach were all divided with GIA staplers and sent as one specimen. No other abnormalities were identified. The stomach was closed with a GIA stapler and oversewn with 2-0 PDS suture. The transverse colon anastomosis was performed with an 80 millimeter GIA stapler and oversewn with 3-0 PDS suture. The fascial defect was supported posteriorly with a 10 x 16 Strattice underlay mesh, which was tacked in position with transfascial #1 Vicryl sutures. The fascia was closed primarily with the exception of a small intentional defect in the mid aspect to allow the wound VAC sponge to evacuate fluid collections beneath the fascia and the mesh.

TECHNIQUE: The patient was brought to the operating room, placed supine on the table. After adequate anesthesia, he was prepped and draped in standard surgical fashion. The abdomen was entered via the incision above and below the palpable hernia mesh and the defect. The mesh was excised from the fascia with electrocautery, which was vast majority of the case, mobilizing and excising the mesh. The mesh was excised from the fascia. After circumferential excision of the mesh, the adherent bowel beneath the mesh was excised and the hernia mesh, and the fistula tracts into the stomach and the colon were clearly identified. On either side of the colon fistula tract, a GIA stapler was used to divide the colon and the mesentery was divided with a LigaSure device. The stomach was opened and at this point using a PEG gastrostomy kit. Angiocath was introduced into the stomach and the wire was fed through the stomach and the opening fistula tract. The PEG tube was fastened to the wire and then the wire was brought through the abdominal wall with the same Angiocath. The PEG was then brought through the fistula tract through the anterior aspect of the stomach and secured to the skin. At this point, the gastrotomy was then closed with an 80 millimeter GIA stapler and a gastrotomy staple line was oversewn with 2-0 PDS suture. The PEG was secured to the posterior fascia with 4 circumferential 3-0 Vicryl sutures. The transverse colon anastomosis was then performed in a side-to-side fashion with an 80 millimeter GIA stapler and closed with the same stapler. All staple lines were oversewn with 3-0 PDS suture. The mesenteric defect within the colon anastomosis was minimal. The abdomen was inspected. Hemostasis was obtained and 10 x16 Strattice mesh was then placed in the posterior aspect of the fascia and tacked with interrupted #1 Vicryl transfascial sutures. After positioning of the mesh, the fascia was then closed primarily with a #1 Vicryl suture and met in the middle, an intentional small defect was left to allow adequate drainage in the space between the mesh and the fascia. The patient was stable throughout the operation, and we sent to the ICU for overnight vent weaning. A wound VAC was placed on the lower aspect of the incision as well using a small sponge.
 
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