Just when I had this coded out, someone suggested that I was wrong. I am now looking for someone else's input.
Exploratory laparotomy in altered field, lysis of adhesions, sigmoid colectomy with end-colostomy, small bowel resection and takedown of splenic flexure.
DESCRIPTION OF PROCEDURE
... The patient's obese abdomen was noteworthy for previous lower midline incision with multiple hernias. The incision was carried down through subcutaneous tissues. Ultimately, I was able to enter the peritoneal cavity. Adherent incarcerated omentum was noted within a relatively large hernia sac. Small bowel was markedly adherent to the anterior abdominal wall as well. This was ultimately down. Bleeding was encountered which was primarily oozing without disturbing any major vessels. The incision was carried down to the level of the symphysis pubis. Once this was done and incision carried to the level of the previous umbilicus, the Bookwalter retractor was placed. We were able to mobilize the colon somewhat. The colon was then divided distally; it was significantly distended proximally. The process appeared to be related to stricturing narrowing in approximately the mid sigmoid colon. Because of the patient's size and distention, dissection continue to be difficult. Ultimately, it was decided to extend the incision significantly proximally. Small bowel decompression was performed, first by doing enterotomy in the mid bowel at a site where the patient had marked small bowel adhesions. The patient had much feculent material in the small bowel and this was able to be aspirated. The small bowel was then decompressed proximally and distally. The GIA stapler was then applied. Attention was then turned to the colon. The colon was markedly distended, especially the transverse colon with the appearance of some vascular compromise. The colotomy was made and a ventilating tube was placed within the bowel to allow for evacuation of the air and feces. Once this was done, the enterotomy was closed with TA-60 stapler with green staples. With the small bowel wall decompressed as well as the colon, we were able to mobilize the left colon from the left gutter in the white line of Toldt. The splenic flexure was taken down utilizing the harmonic scalpel and electrocautery. Ultimately, we had adequate length of colon. The abdomen was thoroughly irrigated with antibiotic solution. The involved segment was well resected and passed off. Because of the bleeding issues, hypotension and other significant issues, the decision was to proceed with colostomy and avoid anastomosis. The small bowel that was resected had been passed off and the small bowel anastomosis performed by placing stay suture of 3-0 silk. The functional end-to-end anastomosis was performed with the GIA stapler. The enterotomy was closed with the TA-60 with green staples. Ultimately, the rent in the mesentery was closed with 2-0 Vicryl. The colostomy was then performed by bringing the distal sigmoid out to the skin. The abdomen was thoroughly irrigated with antibiotic solution. The midline incision was closed with running double-stranded #1 PDS suture. Retention sutures of #1 nylon were placed. The skin was closed with staples. The colostomy was matured by placing 3-0 silk sutures to the fascia and the bowel. The mucosa was then sutured to the skin in an everting suture of 3-0 Vicryl...
Thank you so much for any and all input.
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