Anyone agree with 44620 w/ 44372 ?? Lost! help if possible...TY


PREOPERATIVE DIAGNOSIS: Bowel in discontinuity with an open abdomen.

POSTOPERATIVE DIAGNOSIS: Bowel in discontinuity with an open abdomen.

PROCEDURES:
1. Reexploration of the abdomen.
2. Ileostomy.
3. Feeding jejunostomy.
4. Replacement of abdominal wound VAC.

SPECIMENS: Included the distal small bowel.

INDICATIONS: Pt has undergone several previous operations after being shot in the abdomen. Please see the separately dictated operative reports for the details of those procedures. His last procedure he was left with an open abdomen. As he had a significant amount of necrotic bowel, a prolonged operation and a continued need for reexamination, the decision was made to postpone his ileostomy formation.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. His abdomen was prepped and draped. The abdominal wound VAC was removed. Of note, there appeared to be bilious staining on the sponge of the wound VAC. Once the sponge was removed from the abdomen it was thoroughly examined. The bowel was noted to be significantly edematous. The distal ileum staple line was not intact. The mesenteric aspect of the staple line appeared to have dehisced. There is bilious staining with bowel content contamination throughout the abdomen. The spillage was controlled using silk sutures to close the leak region. The abdomen was then copiously irrigated with sterile normal saline. The abdomen was then again reexplored. Beginning in the left upper quadrant, there was some purulent drainage with some necrotic debris in the splenic fossa, but the posterior aspect of the stomach as well as the pancreatic stump appeared to be viable with no evidence of ongoing bleeding or injury. The liver and gallbladder were intact with no evidence of injury. The left colon was reexamined from the long Hartmann's pouch to the rectum. There is no evidence of perforation or further infarcted bowel. The small bowel was then run from the ligament of Treitz to the ileum. There was fibrinous debris over the entirety of the small bowel, but no further evidence of necrosis or ischemia. The mesentery was thick and edematous. The distal aspect of the ileum was examined and a separate skin incision was then made in the right lower quadrant for the stoma. The circular incision was carried down to the fat through the fascia which was then incised in a cruciate manner. The rectus muscle was bluntly divided and the distal end was brought through the defect. The thickened mesentery appeared to be inhibiting blood flow to the exteriorized bowel, and at the demarcationsite, the bowel was again divided and passed off the field as specimen. Attention was then turned towards the jejunum approximately 40 cm from the ligament of Treitz, the location was determined for the feeding jejunostomy. The jejunal site was identified using a pursestring suture. An enterotomy was then performed and the jejunal tube was then advanced. The tube was then plicated using Witzel-type sutures. The jejunum was then secured to the wall at the site of entry of the feeding tube. An attempt was made to close the abdomen; however, the continued swelling from the anasarca made this difficult as he did experience a rise in his peak pressures. The decision was made to leave the abdomen open and to bring him back in approximately 48 hours to again try to close his abdomen. Attention was then turned back towards the ileostomy which was then formed in standard Brooke fashion using 3-0 interrupted sutures. Once the bowel was transected and appeared to be viable, but edematous, the stoma was matured in standard fashion. The wound VAC was then replaced, and a stoma bag was placed. A fresh JP was then placed through the previous JP tract and the drain laid out the pancreatic bed. The wound VAC was then draped in standard fashion.