patti66
Contributor
Post-op Diagnosis
* Constipation [K59.00]
Procedures
* COLECTOMY TOTAL LAPAROSCOPIC, ILEORECTAL ANASTOMOSIS, LYSIS OF ADHESIONS
Due to the complex nature of this case I will be using an assistant surgeon. Assistant assisted with the surgery by performing tasks are not limited to the following: Handing of the tissue, use of surgical instruments, providing exposure, suturing, opinion and conduct of the surgery. An assistant is generally required to perform any surgery that is performed in the operating room
Procedure Details: The patient was placed under excellent general endotracheal tube anesthesia. IV antibiotics were given. Sequential teds were on at all times. Orogastric tube and Foley catheter were inserted. Patient is placed in modified lithotomy position. The abdomen was prepped with ChloraPrep and draped sterilely.
Small incision was made above the umbilicus and with the abdominal elevated Veress needle inserted. Excellent pneumoperitoneum to 15 mmHg resulted. 12 mm trochars placed at this site. Laparoscope was inserted and extensive adhesions between the omentum and anterior abdominal wall were seen. 2 5 mm trochars could be placed under direct vision in the left upper left lower quadrants. Using traction countertraction and harmonic scalpel with Metzenbaums adhesions were taken down. The omentum was free and could be retracted over the colon. Retrocolic Roux-en-Y gastric jejunostomy for bariatric surgery was seen. There were no adhesions to the small bowel. The pelvis was status post TAH/BSO. Patient had a previous abdominoplasty which she did not tell me. She had a prior jejunostomy but the small bowel was not adherent to the anterior abdominal wall. 2 more 5 mm ports were placed in the right upper and right lower quadrants.
Attention was directed to mobilizing the colon laparoscopically. It was exceptionally long redundant and many folded upon itself. With careful traction countertraction and dissection the cecum and ascending colon were mobilized by incising the lateral and inferior peritoneal attachments. Sigmoid colon was then mobilized. The epiploic appendages were attached to the left upper quadrant. Slow but sure the attachments were all taken down. The right side of her sigmoid mesentery was somewhat adherent to the sacral promontory and an unusual. Care was taken to identify the left ureter and it was swept out of harm's way. Descending colon was mobilized by incising lateral peritoneal attachments up to the splenic flexure. Splenic flexure was mobilized with great care. The spleen was not attached to the colon. The left kidney was noted to be somewhat mobile but was dissected away from the proximal descending colon attachments in the splenic flexure. Next the hepatic flexure was somewhat fused to the prior cholecystectomy site. Some attachments were taken down to avoid traction on the liver. Next of the ileocolic artery and vein were placed on traction and dissected with harmonic scalpel and then divided with LigaSure. The posterior aspect of the right colon was freed from the retroperitoneal attachments with traction countertraction and sweeping with Kitner and then dividing the peritoneal attachments with harmonic scalpel. Duodenum was quite medial and identified and swept posteriorly out of the way. The last attachments between the transverse colon and hepatic flexure and the liver were taken down and the entire right colon was mobilized. Finally the transverse colon was mobilized as well by dividing ileocolic artery and drains with LigaSure, entering the lesser sac, and avoiding injury to the retrocolic gastrojejunostomy. Once all the colon was mobilized the vessels were sequentially ligated and coagulated with LigaSure.
The junction between the sigmoid colon and rectum was identified and the mesorectum coagulated with LigaSure. The proximal rectum was then divided with 3 firings of the Endo GIA 60 3.5 stapler. The cut end of the colon was grasped. Small incision was made around the umbilicus incorporating the umbilical port. Subcutaneous tissue and fascia were divided electrocautery. The entire colon was then delivered through the wound.
Remaining mesentery to the terminal ileum was coagulated LigaSure. The bowel was divided between pursestring device and Kocher clamp and 29 mm circular stapler anvil was placed and pursestring tied. Mucosa noted to be pink and healthy and well perfused. The bowel was irrigated and passed back in the abdomen.
Incision was closed by approximating the fascia with interrupted #1 PDS sutures and tying in the middle. Pneumoperitoneum was reestablished. Dr. Y passed the 29 EEA powered stapler to the rectum and a 29 mm stapler anastomosis was performed. 2 excellent anastomotic rings were seen. There is no tension on the anastomosis. The distal small bowel was occluded and rectum insufflated under saline and no bubbles were seen. The saline was suctioned. The dissection planes were inspected and there was good hemostasis.
Pneumoperitoneum was released and the 5 mm trochars removed. The wounds were irrigated and skin approximated either interrupted inverted or running subcuticular 4-0 Monocryl suture. Steri-Strips applied. Wounds were dressed with 4 x 4 and tape. Patient taken lithotomy reversed extubated taken to PACU in stable condition.
Findings: Long redundant colon with complex anatomy
* Constipation [K59.00]
Procedures
* COLECTOMY TOTAL LAPAROSCOPIC, ILEORECTAL ANASTOMOSIS, LYSIS OF ADHESIONS
Due to the complex nature of this case I will be using an assistant surgeon. Assistant assisted with the surgery by performing tasks are not limited to the following: Handing of the tissue, use of surgical instruments, providing exposure, suturing, opinion and conduct of the surgery. An assistant is generally required to perform any surgery that is performed in the operating room
Procedure Details: The patient was placed under excellent general endotracheal tube anesthesia. IV antibiotics were given. Sequential teds were on at all times. Orogastric tube and Foley catheter were inserted. Patient is placed in modified lithotomy position. The abdomen was prepped with ChloraPrep and draped sterilely.
Small incision was made above the umbilicus and with the abdominal elevated Veress needle inserted. Excellent pneumoperitoneum to 15 mmHg resulted. 12 mm trochars placed at this site. Laparoscope was inserted and extensive adhesions between the omentum and anterior abdominal wall were seen. 2 5 mm trochars could be placed under direct vision in the left upper left lower quadrants. Using traction countertraction and harmonic scalpel with Metzenbaums adhesions were taken down. The omentum was free and could be retracted over the colon. Retrocolic Roux-en-Y gastric jejunostomy for bariatric surgery was seen. There were no adhesions to the small bowel. The pelvis was status post TAH/BSO. Patient had a previous abdominoplasty which she did not tell me. She had a prior jejunostomy but the small bowel was not adherent to the anterior abdominal wall. 2 more 5 mm ports were placed in the right upper and right lower quadrants.
Attention was directed to mobilizing the colon laparoscopically. It was exceptionally long redundant and many folded upon itself. With careful traction countertraction and dissection the cecum and ascending colon were mobilized by incising the lateral and inferior peritoneal attachments. Sigmoid colon was then mobilized. The epiploic appendages were attached to the left upper quadrant. Slow but sure the attachments were all taken down. The right side of her sigmoid mesentery was somewhat adherent to the sacral promontory and an unusual. Care was taken to identify the left ureter and it was swept out of harm's way. Descending colon was mobilized by incising lateral peritoneal attachments up to the splenic flexure. Splenic flexure was mobilized with great care. The spleen was not attached to the colon. The left kidney was noted to be somewhat mobile but was dissected away from the proximal descending colon attachments in the splenic flexure. Next the hepatic flexure was somewhat fused to the prior cholecystectomy site. Some attachments were taken down to avoid traction on the liver. Next of the ileocolic artery and vein were placed on traction and dissected with harmonic scalpel and then divided with LigaSure. The posterior aspect of the right colon was freed from the retroperitoneal attachments with traction countertraction and sweeping with Kitner and then dividing the peritoneal attachments with harmonic scalpel. Duodenum was quite medial and identified and swept posteriorly out of the way. The last attachments between the transverse colon and hepatic flexure and the liver were taken down and the entire right colon was mobilized. Finally the transverse colon was mobilized as well by dividing ileocolic artery and drains with LigaSure, entering the lesser sac, and avoiding injury to the retrocolic gastrojejunostomy. Once all the colon was mobilized the vessels were sequentially ligated and coagulated with LigaSure.
The junction between the sigmoid colon and rectum was identified and the mesorectum coagulated with LigaSure. The proximal rectum was then divided with 3 firings of the Endo GIA 60 3.5 stapler. The cut end of the colon was grasped. Small incision was made around the umbilicus incorporating the umbilical port. Subcutaneous tissue and fascia were divided electrocautery. The entire colon was then delivered through the wound.
Remaining mesentery to the terminal ileum was coagulated LigaSure. The bowel was divided between pursestring device and Kocher clamp and 29 mm circular stapler anvil was placed and pursestring tied. Mucosa noted to be pink and healthy and well perfused. The bowel was irrigated and passed back in the abdomen.
Incision was closed by approximating the fascia with interrupted #1 PDS sutures and tying in the middle. Pneumoperitoneum was reestablished. Dr. Y passed the 29 EEA powered stapler to the rectum and a 29 mm stapler anastomosis was performed. 2 excellent anastomotic rings were seen. There is no tension on the anastomosis. The distal small bowel was occluded and rectum insufflated under saline and no bubbles were seen. The saline was suctioned. The dissection planes were inspected and there was good hemostasis.
Pneumoperitoneum was released and the 5 mm trochars removed. The wounds were irrigated and skin approximated either interrupted inverted or running subcuticular 4-0 Monocryl suture. Steri-Strips applied. Wounds were dressed with 4 x 4 and tape. Patient taken lithotomy reversed extubated taken to PACU in stable condition.
Findings: Long redundant colon with complex anatomy
