lcathey@smsc.org
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Looking at 44970 and 44140 or should it just be the 44140? I would appreciate any input.
PREOPERATIVE DIAGNOSIS:
Cecal polyp.
POSTOPERATIVE DIAGNOSIS:
1. Cecal polyp.
2. Intraabdominal adhesions.
PROCEDURE PERFORMED:
1. Laparoscopic lysis of adhesions.
2. Laparoscopic appendectomy.
3. Open cecotomy with cecal polypectomy.
FINDINGS:
See summary below.
DESCRIPTION OF PROCEDURE:
After induction of adequate general endotracheal anesthesia and insertion of a Foley catheter and orogastric tube, the abdomen was prepped and draped in sterile fashion. Utilizing a supraumbilical curved scar, the Hasson trocar was inserted under direct visualization, and CO2 pneumoperitoneum was established. Laparoscopic inspection revealed a dense wall of omental and small bowel adhesions in the infraumbilical midline, and to facilitate placement of the other trocars, it was felt that lysis of at least part of these adhesions would be required. In this regard, a 5 mm trocar site was established in the right upper quadrant, and carefully by sharp dissection the adhesions were lysed. This then facilitated positioning of a 5 mm trocar in the left lower quadrant, and laparoscopic inspection was carried out. The liver had a smooth glistening surface and no obvious abnormalities. The small bowel where visualized, except for those loops involved in the adhesive process, was unremarkable. The cecum was elevated up out of the pelvis and was actually very near the costal margin. As the dissection progressed in exposing the cecum, it appeared that the cecum was tethered by retrocecal atrophic appendix. It was thought that by removing the appendix, that would facilitate elevation of the cecum, and in this regard the base of the appendix and the mesoappendix were ligated with Endo GIA stapler and the appendix removed with an Endopouch via the Hasson trocar site. This indeed did facilitate exposure of the right colic gutter, and this was incised with cautery for several centimeters, facilitating mobility of the cecum. With the cecum thus mobilized, an area in the right upper quadrant laterally was identified where an open incision could be made to perform the cecotomy and polypectomy. In this regard, laparoscopic instrumentation was removed, and CO2 pneumoperitoneum was released. The Hasson fascial incision was closed with interrupted 0 Vicryl. A transverse incision at the marked spot in the right upper quadrant was made sharply and the abdomen entered through a muscle-splitting approach. The cecum literally protruded through this open incision, having been previously mobilized, and it was delivered into the wound. The ileocecal valve was identified, and over 3-0 silk stay sutures a cecotomy was made directly over the ileocecal valve through the anterior tenia. The 15-20 mm villous polyp was identified just beyond the ileocecal valve as identified endoscopically, and it did not have a malignant appearance, and a simple polypectomy was planned. In this regard, over 3-0 Monocryl stay sutures in the mucosa around the polyp, the polyp was removed full thickness to the submucosal tissue. Grossly normal boundaries were achieved. The defect in the mucosa was then closed with 3-0 Monocryl in a running locking fashion. The seromuscular layer was not violated. The cecotomy was then closed at the mucosal layer with running locking 3-0 Monocryl and in the seromuscular layer with interrupted 3-0 silk in Lembert fashion. The cecum was then delivered back into the intraabdominal space and the abdomen copiously irrigated with normal saline. The peritoneum was then closed with running locking #1 Vicryl Plus as was the transversus abdominis fascia. The internal oblique fascia was closed in the same way, serially irrigating each layer at closure. The external oblique fascia was closed with interrupted #1 Vicryl Plus, and the subdermal tissues after irrigation were closed with interrupted 2-0 Monocryl. The skin incision was closed with running 4-0 Stratafix in intracuticular fashion, and the laparoscopic skin incisions were closed with interrupted 4-0 plain gut in intracuticular fashion. All incisions received Steri-Strips and sterile dressings. Final needle, lap, sponge, and instrument counts were reported as correct. She tolerated the procedure well and was taken to Recovery extubated and stable.