POSTOPERATIVE DIAGNOSIS: Descending, sigmoid, rectal, megacolon with a 10 cm anterior rupture at the rectosigmoid with gross fecal contamination.

1. Exploratory laparotomy.
2. Resection of segment of descending colon, sigmoid colon, rectum with over-sewing of the rectal stump.
3. Open abdomen with VAC dressing.
4. Suture repair of a 4 cm complex tongue laceration.

PROCEDURE AND FINDINGS: This patient presented with a seatbelt sign across the lower abdomen, having been a restrained passenger involved in a motor vehicle collision. The patient presented complaining of abdominal discomfort. A CAT scan demonstrated a mega colon with the rectum and sigmoid massively dilated. It was also noted the patient had pneumoperitoneum. The patient's CAT scan findings were consistent with his physical findings, and with that background the patient was advised that he had a situation that required emergency surgery, and he was taken in an emergent fashion to the operating room. The patient underwent intubation in the operating room. A gastric tube was placed. Foley catheter was placed. The patient's abdomen was then prepped and draped in a sterile fashion. The midline was made in the skin, subcutaneous space was entered, and dissection taken down to the midline fascia. This was incised, elevated with Kocher clamps, incised throughout the length of the overlying skin incision. The peritoneum was then entered. Upon entering the peritoneal cavity, there was an odor consistent with feces. The small bowel was eviscerated towards the right side, but as soon as the abdomen was examined inferiorly, it was noted that the patient had a massively dilated colon consistent with findings anatomically similar to those found when a patient has Ogilvie syndrome. The colon, from the mid descending portion down below the peritoneal reflection to the rectum was massively dilated, and on the anterior surface of the colon there was a rent approximately 15 cm in length. The bowel wall was so thin from its apparent chronic distention that it had just ruptured anteriorly and there was gross fecal contamination in the abdomen. Literally handsful of stool were delivered out of the large rent in the colon, and after some of this was removed a 2-0 Vicryl suture was used in a running fashion to simply close this rent to try to prevent further contamination. After this was controlled, the abdomen was examined. There was some minor about a blood found in the abdomen. The left upper quadrant was examined. The spleen appeared to have some adhesions on the anterior surface in an almost adhesion of some of the colo-lieno ligament. It was as if this was adhesed, a part of it appeared to be the diaphragm, which then was tethered down over the anterior surface of the spleen, but the spleen appeared intact and there was no gross blood noted in the belly in the left upper quadrant. The anterior surface of the stomach was examined. The patient had some stringy adhesions on the anterior surface of the liver and in the left upper quadrant, but the left and right lobe of the liver had no evidence of significant injury. The gallbladder appeared normal. The area of the stomach on to the pylorus appeared grossly normal. The small bowel was examined from the ligament of Treitz to the ileocecal valve and there was no evidence of injury in the small bowel. There was no evidence of mesenteric injury in the small bowel. There was no retroperitoneal hematoma and there is no evidence of retroperitoneal injury. The ascending colon and transverse colon appeared normal, although the patient on palpitation had hard firm stool in the transverse colon. The splenic flexure appeared normal, but at approximately the midportion of the abdomen in the area of the descending colon. At this point, there was a tear in the serosal and muscular layer of the colon and some injury to the mesenteric. From this point distally, just beyond this point then the colon became massively dilated with the anatomic appearance as described above. In the area where the colon had ruptured there was some hematoma or staining on the anterior surface, and the decision at this point was that from the area of injury 1st detected in the descending colon down into the pelvic rectal area that the colon would be resected. Anteriorly, the bladder was adherent to the anterior surface of the dilated colon although the bladder appeared intact. Ultimately a plane was able to be developed between the bladder and colon, and the bladder gently dissected free and freed up from the anterior surface of the rectum in this area. The mesentery was scored in the left colic gutter and the perineum was incised in the area of the left colic gutter and the peritoneum incised superiorly and inferiorly extending that part of the dissection down along the colon down to the peritoneal reflection where it was incised and then this peritoneal dissection taken anteriorly. On the right side similarly the peritoneum portion of the mesenteric was incised and this was brought inferiorly and connected up with the similar dissection from the left side. In this way, the colonic mesentery that was proposed the resected was mobilized. Sponge sticks were used to mobilize it further with care being taken to identify the ureters and make sure that they were left out of the area of colonic manipulation. The colon was thus freed and mobilized. Just proximal to the area of the 1st area of injury noted, a GIA stapling device was used to divide the colon. The colonic mesentery was divided between sequentially placed Kelly clamps and every step is 1 extended from proximal to distal. The vessels feeding the colon to be resected were controlled between Kelly clamps, incised and controlled with silk ties. The vessels were identified and they were doubly tied with silk ties. The descending colon and then the sigmoid were dissected free, and the dissection then taken down over the pelvic brim down into the pelvis itself. Mesenteric vessels were taken right near the surface of the bowel to be resected, controlled as described with Kelly clamps and ties. Ultimately the rectum was dissected free down into the pelvis and at a point beyond the length that had been noted in the colon partially down into the pelvis, the rectum was still massively dilated. Noncrushing bowel clamps were placed, and in series one next to the other, down on the rectum in the pelvis care was taken to make sure that the ureters were not involved in any of this dissection or resection and then the rectum was divided with a heavy scissor and the specimen removed from the field. Intraoperative photographs were taken that should become part of the medical record. The distal stump, which was down into the true pelvis and had feces on its surface, was oversewn closed with a running #1 PDS suture done in a running locking fashion. Given the dimensions of the rectum and the nature of the friable tissue the 1 PDS was chosen because of the large size of the needle which was what was needed to be able to affect an over-sewing of this anatomically abnormal bowel. When this was completed, the abdomen was copiously irrigated with multiple washings of warm saline solution. There was no leakage of stool noted from the oversewn rectal stump and the careful exploratory laparotomy that had been performed before was repeated with no evidence of further injury and no bleeding noted. The decision was made given the gross fecal contamination not to close the abdomen, and as the abdomen was not going to be closed the decision was made to leave the descending colon that had been stapled, to leave it in the stapled manner and not perform a colostomy at this procedure. The abdomen was copiously irrigated with multiple liters of warm saline, but even when this was completed, in examining surface of the bowel and such there were little flex of feces noted here and there around the abdomen. As much cleaning out as could be done was done. The VAC dressing was placed. The Abthera device was used. The inner portion of the device was fashioned to the appropriate dimensions and prepared. It was placed within the peritoneal cavity. The sponge was then placed on top of the layer of this between the open skin edges and ultimately secured in place by stapling it to the skin edges and then the layers of closure closing occlusive dressing were placed on top and the device fashioned to suction. At this point then, after the abdomen had been closed, the surgeons removed their gowns. New gloves were used, fresh instruments were used, and the patient had a tongue laceration that was complex and in a Y-shaped configuration was repaired. A 3-0 chromic suture was used. Initially, a tacking suture was placed to bring 1 edge of the tongue together with the the opposite side of the tongue where the base of the Y would be the V portion of the Y. The stay suture was placed. Then the stem portion of the Y was closed with a running chromic suture, and then another running chromic suture was used to close the remaining portion of the Y. The patient was then delivered to the intensive care unit in a critical condition.