herrera4
Guru
Pt came in 2 weeks ago had
Extended ileocolectomy with transverse colectomy and en bloc small bowel resection. This was followed by wedge resection of subserosal gastric nodule.
came back yesterday-op note....
FINDINGS: Operative findings included a large amount of purulent material within the pelvis. There was an anastomotic leak in the ileocolonic staple line. The anastomosis was widely patent. During mobilization of the segment of bowel immediately adjacent to the previous anastomosis was quite beat up with several serosal tears. This was therefore resected.
PROCEDURE: The patient was brought to the Operating Room and placed in a supine position. Upon induction of general anesthesia she was prepped and draped in the usual sterile fashion using ChloraPrep after a Foley catheter was placed by nursing staff. The previous staples were removed and it became apparent that the patient had undergone necrosis of a 3 x 4 cm segment of the abdominal wall secondary to the infectious process. The necrotic fascia and subcutaneous tissue were debrided and the remaining closure sutures removed. The abdomen was copiously irrigated with saline solution. Multiple interloop collections were broken up. The small bowel was gently mobilized from the retroperitoneum without enterotomy. Within the pelvis there was a large amount of purulent material. This was suctioned free and copious irrigation was carried out of the pelvis as well as the entire abdomen and the right and left subphrenic spaces. Once the interloop adhesions were broken down it became apparent that a leak had occurred at the ileocolonic anastomosis. Here an approximately 8 mm area in the anterior portion of the staple line had opened. Staples did appear to be formed. The small bowel was mobilized as was additional adhesions between the transverse colon and the stomach. The bowel was then divided using an Endo-GIA with the purple load for the colon and the Endo-GIA using the tan load for the ileum. As noted above, there was a portion of the small bowel approximately 20 cm which was quite beat up from the mobilization with serosal tears. These were initially repaired but a decision was made to resect this to avoid a potential for leak in the future. A functional end-to-end anastomosis was then carried out using the Endo-GIA with the purple load. The common opening was closed using the TA-90 green stapler load. The corners of the anastomosis were reinforced with multiple sutures of 3-0 silk. Tisseel was then sprayed on the anastomosis and mesenteric defects were closed with running 3-0 PDS. Due to the tissue loss in the upper abdomen skin flaps were elevated in the superior abdomen in the upper portion to allow for a tension free closure of the midline. The necrotic fascia was resected using cautery as was the necrotic fat. Copious irrigation was then carried out. An ileostomy was then fashioned in the right lower quadrant through the right rectus muscle. A window was made in the ileal mesentery and this was brought through the fascial defect for the ileostomy using a Penrose drain. This was accomplished after excising a disk of skin and subcu and making a cruciate incision in the fascia. The abdomen was then closed with a running looped #1 PDS. A separate drain was placed subjacent to the incision. The ileostomy appliance was applied and the bridge was placed. The ileostomy was then matured using multiple sutures of 3-0 Vicryl. .....
any help is appreciated
Extended ileocolectomy with transverse colectomy and en bloc small bowel resection. This was followed by wedge resection of subserosal gastric nodule.
came back yesterday-op note....
FINDINGS: Operative findings included a large amount of purulent material within the pelvis. There was an anastomotic leak in the ileocolonic staple line. The anastomosis was widely patent. During mobilization of the segment of bowel immediately adjacent to the previous anastomosis was quite beat up with several serosal tears. This was therefore resected.
PROCEDURE: The patient was brought to the Operating Room and placed in a supine position. Upon induction of general anesthesia she was prepped and draped in the usual sterile fashion using ChloraPrep after a Foley catheter was placed by nursing staff. The previous staples were removed and it became apparent that the patient had undergone necrosis of a 3 x 4 cm segment of the abdominal wall secondary to the infectious process. The necrotic fascia and subcutaneous tissue were debrided and the remaining closure sutures removed. The abdomen was copiously irrigated with saline solution. Multiple interloop collections were broken up. The small bowel was gently mobilized from the retroperitoneum without enterotomy. Within the pelvis there was a large amount of purulent material. This was suctioned free and copious irrigation was carried out of the pelvis as well as the entire abdomen and the right and left subphrenic spaces. Once the interloop adhesions were broken down it became apparent that a leak had occurred at the ileocolonic anastomosis. Here an approximately 8 mm area in the anterior portion of the staple line had opened. Staples did appear to be formed. The small bowel was mobilized as was additional adhesions between the transverse colon and the stomach. The bowel was then divided using an Endo-GIA with the purple load for the colon and the Endo-GIA using the tan load for the ileum. As noted above, there was a portion of the small bowel approximately 20 cm which was quite beat up from the mobilization with serosal tears. These were initially repaired but a decision was made to resect this to avoid a potential for leak in the future. A functional end-to-end anastomosis was then carried out using the Endo-GIA with the purple load. The common opening was closed using the TA-90 green stapler load. The corners of the anastomosis were reinforced with multiple sutures of 3-0 silk. Tisseel was then sprayed on the anastomosis and mesenteric defects were closed with running 3-0 PDS. Due to the tissue loss in the upper abdomen skin flaps were elevated in the superior abdomen in the upper portion to allow for a tension free closure of the midline. The necrotic fascia was resected using cautery as was the necrotic fat. Copious irrigation was then carried out. An ileostomy was then fashioned in the right lower quadrant through the right rectus muscle. A window was made in the ileal mesentery and this was brought through the fascial defect for the ileostomy using a Penrose drain. This was accomplished after excising a disk of skin and subcu and making a cruciate incision in the fascia. The abdomen was then closed with a running looped #1 PDS. A separate drain was placed subjacent to the incision. The ileostomy appliance was applied and the bridge was placed. The ileostomy was then matured using multiple sutures of 3-0 Vicryl. .....
any help is appreciated