PROCEDURES PERFORMED:
1. Exploratory laparotomy with partial colectomy and low pelvic anastomosis.
2. Diverting loop ileostomy.
3. Colostomy closure.
4. Enterolysis (1 hour time).
ESTIMATED BLOOD LOSS: 100 mL.
COMPLICATIONS: None apparent.
SPECIMENS:
1. Descending colon and end colostomy.
2. Large patch of hypertrophic skin.
INDICATION FOR THE PROCEDURE: The patient is a very pleasant and unfortunate
47-year-old gentleman who back in 02/2020 had to undergo an emergency
laparotomy for fecal peritonitis. At that time, the patient ended up with an
end colostomy and Hartmann pouch. The patient had complicated recovery
afterwards which required hospitalization in the intensive care unit for a long
time on up to 3 pressors. At that time as a consequence of that, the patient
developed an end colostomy stricture. He has been undergoing periodic
dilatation of his end colostomy and we were getting ready to schedule the
colostomy takedown for the patient. He had an episode of a complete
obstruction over the past weekend and underwent further dilatation of the
ostomy stricture. The patient was discharged to home, did well; however, he
notified me yesterday that he was feeling weak and had not been able to eat or
drink anything because of nausea and anorexia. The patient was asked to come
to the emergency department for an evaluation where he was identified to have
an elevated lactic acid with severe dehydration. His CT scan of the abdomen
and pelvis revealed the presence of some fluid, which was intraperitoneal as
well as some free air consistent with a bowel perforation. The patient was
admitted to the intensive care unit, fluid resuscitated and recommended to
consider an urgent laparotomy. I discussed with him and his wife the benefits
and risks of the procedure and they granted consent.
PROCEDURE PERFORMED AS FOLLOWS: After informed consent was obtained from the
patient, the patient was taken to the operating room. He was placed on the
operating table in the supine position and general anesthesia was induced.
After induction of the general anesthesia, the patient was positioned on the
table, was switched to a modified Lloyd-Davies. The patient's abdomen,
perineum, and perianal areas were then prepped and draped in the usual sterile
fashion. Using #10 scalpel blade, an elliptic incision around the large
hypertrophic scar that the patient had in his abdomen was made. Incision was
carried at the top of the incision down to the fascia. The fascia was then
divided with the electrocautery, was grasped in between clamps and very
carefully, the preperitoneal space was separated from that large hypertrophic
scar. The scar was carefully excised during this maneuver, we eventually got
intraperitoneal. The patient had several adhesions to the abdominal wall of
the small bowel and once all the hypertrophic scar had been removed and we had
entered the abdominal cavity along the incision, careful enterolysis took place
to try to identify the intra-abdominal anatomy. The patient had a large amount
of fecal material in the peritoneal cavity, all of which was suctioned out and
lavaged. An extensive enterolysis took place, which took us approximately 1
hour of time until we were able to separate all the intestine from the
patient's pelvis. The rectal stump was identified. A Bookwalter retractor was
set in place and the rectum was carefully dissected out to expose the rectal
stump and free it up to expose it well for an anastomosis. Subsequently, the
area of the colostomy was cored out all the way down to the fascia. The
colostomy was carefully separated from the fascia and pushed back into the
abdominal cavity. Mobilization of the descending colon then took place all the
way up to the splenic flexure until we were able to mobilize enough of the
descending colon that we could construct a low pelvic anastomosis. The end of
the ostomy and the area of perforation which was located right at the symphysis
of the fascia with the colostomy were then completely excised. A 29 mm CEA
stapler was then brought into the field. A pursestring was created in the
descending colon and a transanal end-to-end anastomosis was constructed. After
the anastomosis was completed, a Glassman clamp was placed on the descending
colon and the anastomosis was tested to pressure and inspected with the rigid
scope. It was well sealed to air and fluid; however, because of the fact that
the patient had fecal contamination and it is likely that he may still require
some pressors while in the intensive care unit, we decided to perform a
diverting loop ileostomy on the right lower quadrant and the orifice for the
ileostomy was constructed. A cruciate incision was made in the anterior rectus
sheath and a single incision on the posterior rectus sheath and the loop was
brought out. His mesentery is very short and it took some work to be able to
bring the loop out. Flaps of the fascia were then raised. The position of the
nasogastric tube was verified to be in the stomach. The fascia was then closed
using #1 PDS running suture at 5mm spacing. An excellent closure was obtained.
The skin was reapproximated using surgical staples. A small opening on the
loop ileostomy was made and the ostomy was matured in a Brooke fashion using
3-0 Vicryl sutures. An ileostomy wafer was placed on the new ileostomy site.
The fascia of the previous end colostomy was closed in 2 layers using #1
Prolene interrupted sutures and the wound was packed with Kerlix embedded in
Betadine. The patient has tolerated the procedure relatively well. He remains
in guarded condition, requiring Norepinephrine to maintain his blood pressure;
he will be transferred back to the intensive care unit, intubated to continue
with his postoperative care.
1. Exploratory laparotomy with partial colectomy and low pelvic anastomosis.
2. Diverting loop ileostomy.
3. Colostomy closure.
4. Enterolysis (1 hour time).
ESTIMATED BLOOD LOSS: 100 mL.
COMPLICATIONS: None apparent.
SPECIMENS:
1. Descending colon and end colostomy.
2. Large patch of hypertrophic skin.
INDICATION FOR THE PROCEDURE: The patient is a very pleasant and unfortunate
47-year-old gentleman who back in 02/2020 had to undergo an emergency
laparotomy for fecal peritonitis. At that time, the patient ended up with an
end colostomy and Hartmann pouch. The patient had complicated recovery
afterwards which required hospitalization in the intensive care unit for a long
time on up to 3 pressors. At that time as a consequence of that, the patient
developed an end colostomy stricture. He has been undergoing periodic
dilatation of his end colostomy and we were getting ready to schedule the
colostomy takedown for the patient. He had an episode of a complete
obstruction over the past weekend and underwent further dilatation of the
ostomy stricture. The patient was discharged to home, did well; however, he
notified me yesterday that he was feeling weak and had not been able to eat or
drink anything because of nausea and anorexia. The patient was asked to come
to the emergency department for an evaluation where he was identified to have
an elevated lactic acid with severe dehydration. His CT scan of the abdomen
and pelvis revealed the presence of some fluid, which was intraperitoneal as
well as some free air consistent with a bowel perforation. The patient was
admitted to the intensive care unit, fluid resuscitated and recommended to
consider an urgent laparotomy. I discussed with him and his wife the benefits
and risks of the procedure and they granted consent.
PROCEDURE PERFORMED AS FOLLOWS: After informed consent was obtained from the
patient, the patient was taken to the operating room. He was placed on the
operating table in the supine position and general anesthesia was induced.
After induction of the general anesthesia, the patient was positioned on the
table, was switched to a modified Lloyd-Davies. The patient's abdomen,
perineum, and perianal areas were then prepped and draped in the usual sterile
fashion. Using #10 scalpel blade, an elliptic incision around the large
hypertrophic scar that the patient had in his abdomen was made. Incision was
carried at the top of the incision down to the fascia. The fascia was then
divided with the electrocautery, was grasped in between clamps and very
carefully, the preperitoneal space was separated from that large hypertrophic
scar. The scar was carefully excised during this maneuver, we eventually got
intraperitoneal. The patient had several adhesions to the abdominal wall of
the small bowel and once all the hypertrophic scar had been removed and we had
entered the abdominal cavity along the incision, careful enterolysis took place
to try to identify the intra-abdominal anatomy. The patient had a large amount
of fecal material in the peritoneal cavity, all of which was suctioned out and
lavaged. An extensive enterolysis took place, which took us approximately 1
hour of time until we were able to separate all the intestine from the
patient's pelvis. The rectal stump was identified. A Bookwalter retractor was
set in place and the rectum was carefully dissected out to expose the rectal
stump and free it up to expose it well for an anastomosis. Subsequently, the
area of the colostomy was cored out all the way down to the fascia. The
colostomy was carefully separated from the fascia and pushed back into the
abdominal cavity. Mobilization of the descending colon then took place all the
way up to the splenic flexure until we were able to mobilize enough of the
descending colon that we could construct a low pelvic anastomosis. The end of
the ostomy and the area of perforation which was located right at the symphysis
of the fascia with the colostomy were then completely excised. A 29 mm CEA
stapler was then brought into the field. A pursestring was created in the
descending colon and a transanal end-to-end anastomosis was constructed. After
the anastomosis was completed, a Glassman clamp was placed on the descending
colon and the anastomosis was tested to pressure and inspected with the rigid
scope. It was well sealed to air and fluid; however, because of the fact that
the patient had fecal contamination and it is likely that he may still require
some pressors while in the intensive care unit, we decided to perform a
diverting loop ileostomy on the right lower quadrant and the orifice for the
ileostomy was constructed. A cruciate incision was made in the anterior rectus
sheath and a single incision on the posterior rectus sheath and the loop was
brought out. His mesentery is very short and it took some work to be able to
bring the loop out. Flaps of the fascia were then raised. The position of the
nasogastric tube was verified to be in the stomach. The fascia was then closed
using #1 PDS running suture at 5mm spacing. An excellent closure was obtained.
The skin was reapproximated using surgical staples. A small opening on the
loop ileostomy was made and the ostomy was matured in a Brooke fashion using
3-0 Vicryl sutures. An ileostomy wafer was placed on the new ileostomy site.
The fascia of the previous end colostomy was closed in 2 layers using #1
Prolene interrupted sutures and the wound was packed with Kerlix embedded in
Betadine. The patient has tolerated the procedure relatively well. He remains
in guarded condition, requiring Norepinephrine to maintain his blood pressure;
he will be transferred back to the intensive care unit, intubated to continue
with his postoperative care.
