ksb0211
Guest
Thank you so much for taking a look at this. It was a large case and due to everything done, I'm hoping for someone else's input. Thanks.
POSTOPERATIVE DIAGNOSIS
1. Closed loop obstruction.
2. Impending sepsis.
3. Small bowel obstruction.
4. Ventral hernia.
5. Stoma hernia.
PROCEDURE/OPERATION
1. Exploratory laparotomy with lysis of massive adhesions, repair of parastomal hernia, ileostomy.
2. Repair of ventral hernia with extra peritoneal polypropylene mesh.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room. After attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion.
Made a midline incision and entered the abdominal cavity through the defect which was superior. There was just a large ventral defect and then there was a smaller defect just adjacent to the initial defect in the stomal area. There was gut incorporated into both of these areas. We decompressed the intestine. The distal ileum seemed to be edematous, quite bulky and looked like it had suffered some degree of trauma. Once the patient was asleep we were able to reduce the hernia before we opened and probably this resulted in revascularization, so we really did not find as much ischemia as we feared. There was no question that the distal two feet of her ileum were very boggy and edematous consistent with a prior injury. We started a lysis of adhesions and this went pretty well. Eventually I asked for Dr. XXXXX to come in because we were just having difficulty getting some of the adhesions out. We were eventually able to do so and got the adhesions freed up in their entirety so we could trace them from the anastamosis from where they had removed a portion of the ileum for the ileoconduit. We sort of decompressed this gut because all of it was quite edematous and it made it really difficult to work. We decompressed it back up to the stomach and probably took out several hundred milliliters of __________________ which really improved visualization within the intestinal cavity. At this point we carefully reordered the small bowel and entered it back into the abdominal cavity and then lipped it and assessed what defects were present. The stoma defect was quite pronounced and we looked at this thinking how we could repair this. What we elected to do was use a Keel technique using Goretex. We rolled the edges of the Goretex so that it would present a non-rough surface to the ileoconduit itself, rolled that in place and then used a ProTack. Put it into position and then tacked it in place. Once that was done, we then carried out a primary repair of the midline defect. A lot of the fascia here was quite attenuated with the hernia sac and we had some tension, but we really did not want to put mesh inside the abdomen more than we had to. We did run the small bowel carefully before we replaced it within the abdominal cavity and found no leaks. The amount of adhesions that we lysed were really significant and to give an idea how much this was look at the operative timing of this procedure. You can see that we are coming up on four hours on this procedure and most of that time was spent lysing adhesions. We closed the ventral defect after trimming the fascia. We used interrupted figure-of-eight sutures of #1 Prolene and then placed a polypropylene mesh on top on the superior aspect of the fascia fixing it in place with 2-0 Ethibond and got a really nice looking repair out of it. We then placed a 10 mm Jackson-Pratt drain which we secured in place with 2-0 silk and then closed deep tissues with 3-0 Vicryl followed by skin staples. The patient tolerated the procedure quite well.
POSTOPERATIVE DIAGNOSIS
1. Closed loop obstruction.
2. Impending sepsis.
3. Small bowel obstruction.
4. Ventral hernia.
5. Stoma hernia.
PROCEDURE/OPERATION
1. Exploratory laparotomy with lysis of massive adhesions, repair of parastomal hernia, ileostomy.
2. Repair of ventral hernia with extra peritoneal polypropylene mesh.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room. After attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion.
Made a midline incision and entered the abdominal cavity through the defect which was superior. There was just a large ventral defect and then there was a smaller defect just adjacent to the initial defect in the stomal area. There was gut incorporated into both of these areas. We decompressed the intestine. The distal ileum seemed to be edematous, quite bulky and looked like it had suffered some degree of trauma. Once the patient was asleep we were able to reduce the hernia before we opened and probably this resulted in revascularization, so we really did not find as much ischemia as we feared. There was no question that the distal two feet of her ileum were very boggy and edematous consistent with a prior injury. We started a lysis of adhesions and this went pretty well. Eventually I asked for Dr. XXXXX to come in because we were just having difficulty getting some of the adhesions out. We were eventually able to do so and got the adhesions freed up in their entirety so we could trace them from the anastamosis from where they had removed a portion of the ileum for the ileoconduit. We sort of decompressed this gut because all of it was quite edematous and it made it really difficult to work. We decompressed it back up to the stomach and probably took out several hundred milliliters of __________________ which really improved visualization within the intestinal cavity. At this point we carefully reordered the small bowel and entered it back into the abdominal cavity and then lipped it and assessed what defects were present. The stoma defect was quite pronounced and we looked at this thinking how we could repair this. What we elected to do was use a Keel technique using Goretex. We rolled the edges of the Goretex so that it would present a non-rough surface to the ileoconduit itself, rolled that in place and then used a ProTack. Put it into position and then tacked it in place. Once that was done, we then carried out a primary repair of the midline defect. A lot of the fascia here was quite attenuated with the hernia sac and we had some tension, but we really did not want to put mesh inside the abdomen more than we had to. We did run the small bowel carefully before we replaced it within the abdominal cavity and found no leaks. The amount of adhesions that we lysed were really significant and to give an idea how much this was look at the operative timing of this procedure. You can see that we are coming up on four hours on this procedure and most of that time was spent lysing adhesions. We closed the ventral defect after trimming the fascia. We used interrupted figure-of-eight sutures of #1 Prolene and then placed a polypropylene mesh on top on the superior aspect of the fascia fixing it in place with 2-0 Ethibond and got a really nice looking repair out of it. We then placed a 10 mm Jackson-Pratt drain which we secured in place with 2-0 silk and then closed deep tissues with 3-0 Vicryl followed by skin staples. The patient tolerated the procedure quite well.
