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1. Exploratory laparotomy.
2. Resection of approximately a 25-cm section of small bowel with multiple enterotomies.
3. Repair of gunshot wound injury to the dome of urinary bladder.
4. Descending end colostomy.
5. Proctosigmoidoscopy to 20 cm with washout of rectum and distal colon.
PROCEDURE: placed on the OR table in the supine position. After satisfactory induction of orotracheal general anesthesia, the anterior torso was draped and prepped in a sterile manner from the nipples to the groin. The patient's lower extremities were placed in the lithotomy position. Under strict sterile technique, and after a time-out was performed, a midline incision was made from the xiphoid process extending inferiorly to the pubis. Incision was carried down to the midline to the linea alba, and the peritoneal cavity was entered in the usual manner. Upon entering the peritoneal cavity a moderate amount of blood, and succus entericus was encountered. The small bowel was run from the ligament of Treitz to the ileocecal valve. There was approximately six enterotomies in the proximal ileum in a section of approximately 25-cm. These enterotomies were quickly oversewn using a 0-chromic suture. Attention was then directed to all 4 quadrants of the abdomen. There was no active bleeding noted. Spleen and liver appeared normal. The colon appeared grossly normal. The left colon, sigmoid colon was mobilized medially. There was no evidence of colonic sigmoid injury. Attention was then directed back to the section of small bowel with multiple enterotomies. Using the GIA stapling device this 25-cm section of small bowel was transected and removed from the field. A side-to-side anastomosis was then performed using the GIA stapling device, and the remaining enterotomy was closed using a running 3-0 chromic suture, and oversewn using 3-0 silk suture. The mesenteric defect was closed using several 3-0 silk sutures. At this time approximately 300 cc of methylene blue was injected through the Foley catheter, and a small defect to the superior dome of the urinary bladder was identified. This was oversewn using a layer running, full-thickness, of 0-chromic sutures and a second serousal layer of interrupted 3-0 silk suture. Again, methylene blue was injected into the Foley catheter and into the urinary bladder. Again there was contrast noted coming from deep in the pelvis, at the neck of the urinary bladder. This site appeared to be an extraperitoneal site. This could not be definitely identified, and it could not be reached to be oversewn. I then left the operating field to perform a proctosigmoidoscopy. A proctosigmoidoscopy was performed to approximately 20 cm. No definite rectal or distal colon injury was identified, but blood was noted emanating from the rectum. Using non-crushing clamps my assistant gently clamped and occluded the distal sigmoid colon. The rectum and distal colon were irrigated with saline solution several times. I then re-scoped the rectum to approximately 20 cm. Again, blood was noted, but no definite rectal injury was identified. At that time a decision was made to perform a descending end colostomy. Using the GIA stapling device the sigmoid colon was transected. The proximal end was brought out through a skin site in the left lower quadrant of the abdomen. This site was made in the left lower quadrant of the abdomen. An approximately 2-cm in diameter skin incision was made; and using blunt and careful sharp dissection the colostomy site was created. The proximal sigmoid colon was then brought out at this site. The sigmoid stump was placed back into the pelvis, and tagged with a large 0-Prolene sutures. Two large Jackson-Pratt drains were placed in the pelvis, and on either side of the urinary bladder, and brought out through separate stab wounds in the left lower, and right lower quadrants of the abdomen. These were secured in place using 2-0 Prolene sutures. The peritoneal cavity was irrigated with saline solution. Sponge and instrument counts were determined to be correct. The fascia was closed using a running double-stranded PDS suture. Subcutaneous tissues were irrigated, and the skin was loose loosely approximated with staples. The end colostomy was matured in the usual manner, using multiple interrupted 4-0 Vicryl sutures approximating the colonic mucosa to the skin of the anterior abdominal wall in the left lower quadrant. Sterile dressings were applied. Colostomy appliance was applied.