PREOPERATIVE DIAGNOSIS: Perforated viscus.

POSTOPERATIVE DIAGNOSIS: Perforated viscus.

OPERATIONS PERFORMED:
1. Placement of right subclavian vein triple lumen catheter.
2. Exploratory laparotomy.
3. Resection of ileocolonic anastomosis.
4. Creation of ileostomy with placement of Baker’s tube.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ESTIMATED BLOOD LOSS: 400 mL.

URINE OUTPUT: 1250 mL.

INTRAOPERATIVE FLUIDS: 4 units of packed RBCs, 5 liters of crystalloid.

DRAINS:
1. A 19 French round JP.
2. A Baker’s tube passed approximately 10 cm into the distal ileum.

SPECIMEN: Ileocolonic anastomosis.

INTRAOPERATIVE FINDINGS: The prior ileocolonic anastomosis was found to be in a retrogastric position. There was perforation of the anterior staple line with an abscess cavity. This was then resected, and an ileostomy was created.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position on the operating table. Bilateral lower extremity antithrombotic boots were placed. He was then placed under state of general anesthesia with endotracheal intubation. After being anesthetized, he was then placed in Trendelenburg position. His right chest and neck were then prepped and draped in standard surgical fashion using ChloraPrep. A large-bore needle was then used to access the right subclavian vein. This was done on the first attempt. The guidewire passed easily, and the catheter was placed using the Seldinger technique. It was sutured and dressing was applied. The patient was then placed flat. He was prepped and draped in standard surgical fashion using Betadine.

Attention was turned to his prior midline incision. This incision was then carried down through the skin and subcutaneous tissues, and the old fascial suture was then identified and removed. The abdomen was entered. There was some minimal fluid within the abdomen upon entering the abdomen. The dissection was taken down carefully and slowly. There were multiple adhesions. The tissue was quite dense yet friable secondary to the inflammatory changes and recent operation. The anastomosis, which had been located on the CT scan, was noted to be in a retrogastric position.

Attention was then focused there, and we elevated the stomach from the ileocolonic anastomosis. Once this anastomosis was visualized upon elevation of the stomach, there was noted to be an abscess cavity. There was also noted to bilious material in this region. The anastomosis was then identified and freed, and the distal ileum was then transected using the contour stapler. The anastomosis was then freed from the remainder of the tissue carefully, and the colon was then dissected to healthy colon once again using the contour stapler. The staple line was then fired and the specimen was freed.

Upon examination of the colon, the mesenteric border of the colon was noted to be open with mucosa visible; therefore, once again further colon was then dissected to allow for another firing of the contour stapler. The staple line was then examined and was intact. It was then oversewn using 3-0 silk sutures as well. The mesentery of the distal ileum was then freed to the best of our ability, and the fascia was then opened on the right upper quadrant as well as excising skin to elevate the stoma. The stoma was under tension secondary to the inflamed mesentery. Therefore, the bowel was brought up approximately 2 cm through the fat and dermis and was tacked.

The Baker’s tube was then used to intubate the ileostomy and passed in a retrograde fashion to allow for control of the ileum. Once the Baker’s tube was then passed, the tube was secured using 3-0 silk sutures and the end of the stoma was also tacked to the fat and dermis to allow for hopeful creation and control of the fistula. The JP drain was laid in the upper abdomen at the site of the abscess cavity trailing from the ileostomy into the abscess cavity and over the colonic staple line. The JP drain was also secured using 2-0 silk sutures.

The midline incision was then reapproximated using #2 nylon retention sutures and bolsters. The wound was packed using iodoform. The patient was hemodynamically stable during the operation, did not receive any pressors, and was making adequate urine output. He was then transferred from the operating room to the ICU in guarded condition. All sponge, needle, and instrument counts were correct x2 at the end of the case.

CHIEF COMPLAINT: Colovesicular fistula.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male referred by Dr. John Doe for evaluation. The patient has had diverticular disease for about four years, which actually turned out to be almost six years. The patient thought it was a hernia but then he started to have a fever. He went to the emergency room. He had a colonoscopy and was diagnosed with diverticular disease. He did well for a few years and then started to have burning with urination, fevers, hematuria, and pneumaturia. The patient has felt well for two weeks now. He has been on Augmentin and then started ciprofloxacin. He is now starting on Macrodantin. Bowel movements daily are normal without any blood. The patient does have cloudy urine.

PAST MEDICAL HISTORY: Diverticular disease.

PAST SURGICAL HISTORY: The patient has had recurrent cystic hygroma of the left neck area surgically excised.

ALLERGIES: NKDA.

FAMILY HISTORY: Mother with COPD and a heart valve replacement.

SOCIAL HISTORY: The patient drinks three to four alcoholic beverages per week. Denies illicit drug or tobacco use.

REVIEW OF SYSTEMS: Corrective lenses, blood in the urine, burning with urination, and abdominal pain. Otherwise, 14-point ROS is as per HPI.

PHYSICAL EXAMINATION: The patient’s height is 5 feet 10 inches and weight is 252 pounds. There is no scleral icterus. His lungs are CTABL. Heart has S1, S2. Abdomen is soft and tender in the suprapubic area. There is no rebound or guarding. No peritoneal signs. No incisional or congential hernias can be palpated. Extremities are without cyanosis or edema.

The patient’s CT scan of the pelvis showed findings consistent with a diverticulitis and fistula connection to the bladder.

Ultrasound of the abdomen showed probable fatty changes in the liver; however, echotexture heterogeneous micrometastases cannot be excluded. Urinary bladder is very poorly distended. No gallstones are seen.

IMPRESSION: This is a gentleman with a colovesicular fistula from diverticular disease most likely, although malignancy cannot be excluded.

PLAN: We explained to the patient that he needs a colonoscopy to look for any other pathology, as it has been five years since his last colonoscopy. We also feel that he would be a good candidate for a minimally invasive sigmoid colectomy, preferentially done with robotic assistance, and possible closure of the bladder if indicated, but Foley decompression of the bladder would certainly be indicated. Primary anastomosis would be advantageous with bowel preparation ahead of time. Once the colonoscopy is done, we will determine exactly the dates for surgery, and we look forward to taking care of him. Ureteral stents will be used in this case.

PREOPERATIVE DIAGNOSIS: Prolapsed diverting colostomy.

POSTOPERATIVE DIAGNOSIS: Prolapsed diverting colostomy.

PROCEDURE PERFORMED: Partial transverse colectomy and a complex revision of colostomy.

SURGEON: John Doe, MD

ANESTHESIA: General.

SPECIMEN: Transverse colon.

CONDITION: Stable.

INDICATIONS FOR PROCEDURE: This is a (XX)-year-old gentleman with history of obstructing rectal mass who actually had undergone a diverting transverse loop colostomy one month ago. The patient had elected to not proceed with definitive surgical resection after meeting with his primary care physician and his oncologist. The patient was placed mostly on comfort care only. However, over the last three days or so, the patient reports a large amount of rectal tissue protruding through the existing ostomy causing minimal discomfort, but it was noted there is significant decrease of stool output. The patient otherwise has no abdominal pain. Because of the discomfort and partial obstruction as a result of severe edema and the fact that we were unable to reduce the prolapsed portion, the patient now presents to the OR for repair.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the OR and prepped and draped in sterile fashion. An elliptical skin incision was made around the pre-existing ostomy. The transverse colon was then dissected away from the surrounding tissue, and again, there was a large amount of redundant proximal transverse colon that we can easily bring out through this opening. At this point, we elected to resect the redundant transverse colon. The mesentery was then ligated and divided using LigaSure device until just enough of the transverse colon could be brought out to the level of the skin to create the ostomy. At this time, we elected to convert into an end transverse colostomy with a mucous fistula because of the distal obstruction. Some of the distal transverse colon was also resected again just so it was flush with the skin. The proximal portion was then sutured circumferentially to the dermis using 3-0 Vicryl suture. Approximately half of the distal staple line was then excised, and a mucous fistula was then created by again using the similar technique by suturing full thickness of the bowel wall to the dermis circumferentially. The two ends of the colon were also sutured together so it is flush with the skin. The ostomy appliance was then reapplied. The patient was returned to recovery in stable condition.

PREOPERATIVE DIAGNOSIS: Fistula-in-ano.

POSTOPERATIVE DIAGNOSIS: Fistula-in-ano as well as abscess.

OPERATION PERFORMED:
1. Incision and drainage of abscess.
2. Seton fistulotomy x2.

SURGEON: John Doe, MD

ANESTHESIA: General.

FINDINGS AND DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room and placed in the supine position. After adequate induction of general anesthesia, he was placed in the lithotomy position. The perineum was prepped and draped with Betadine.

A perianal block was performed with 30 mL of 0.25% Marcaine with epinephrine. The perianal skin was infected. There was multiple scarring in the areas of induration. On digital rectal exam, the canal was stenotic entirely with very noncompliant tissue. In fact, we were only able to get the smallest Hill-Ferguson retractor within. On examination, there were obvious external openings in the left posterolateral region. One of these was injected with peroxide solution, and upon doing this, multiple fistula tracts all along the left side, about four to five of them, became obvious. On internal inspection, there was clearly an internal opening in the posterior midline.

A probe was inserted through one of these, through the most posterior opening and brought through the internal opening. This was exchanged with a silk suture, which was then exchanged with a metal loop and secured with two sutures of #0 silk. The other fistula tracts were unroofed. The fistula tract was opened up and the granulation tissue curetted out. Upon doing this, we opened into a very large cavity, which was likely a deep postanal space abscess. Also, it extended all along the ischiorectal fossa and lateral to the rectum up for several centimeters. There was copious granulation tissue within this area. It was all curetted out. A second vessel loop was placed at horseshoe extension with fistula just anterior to the other one.

The abscess cavity was then packed with several feet of 1/2-inch Nu Gauze. The patient tolerated the procedure well without any complication. Postoperatively, the patient was extubated and transferred to the recovery in stable condition.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Colonic mass/tumor.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who came in with complaint of lower back pain. During his workup, the patient was found to have low hemoglobin and hematocrit of 8.8 and 28.4. Workup for anemia included colonoscopy performed. During colonoscopy, the patient was found to have a tumor at the ileocecal valve. Pathology of the tumor is pending.

PAST MEDICAL HISTORY: Significant for hypertension, diabetes, history of coronary artery disease and MI in the past. Also, past medical history is significant for hypercholesterolemia and hypothyroidism.

PAST SURGICAL HISTORY: Significant for stent placement.

MEDICATIONS: Aspirin, Advair, insulin, hydrochlorothiazide, lisinopril, Singulair, Synthroid, ranitidine and Zocor.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: Noncontributory.

FAMILY HISTORY: Significant for hypertension, diabetes and CVA.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2 degrees, pulse 76, respirations 18, blood pressure 130/66, and O2 saturation 93%.
HEENT: Examination within normal limits.
CARDIOPULMONARY: Examination within normal limits.
ABDOMEN: Soft, nontender and nondistended. No evidence of hernias or hepatosplenomegaly. Presence of insulin pump was noted in the right lower quadrant.
EXTREMITIES: Examination within normal limits.

LABORATORY DATA: These include CMP revealing sodium 140, potassium 4.2, chloride 106, CO2 of 26, glucose 178, BUN 23, creatinine 1.5, total bilirubin 0.3, alkaline phosphatase 90, ALT 22, and AST 26. CBC on admission revealed hemoglobin of 8.8, hematocrit of 28.4, white cell count 4.8, and platelet count of 394,000.

RADIOLOGICAL DATA: Radiological investigation included lumbar spinal films, four views, and no evidence of acute fracture or acute pathology identified.

ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman who appears to have a tumor located at the ileocecal valve region. Pathology of the tumor is pending. Irrespective of the pathology, the patient would need right hemicolectomy. We have discussed this case in detail with the patient and the patient’s wife. They would like to proceed with this operation during this hospitalization. Before we proceed with the operation, we would like to obtain a CT scan of the abdomen and pelvis and also would request a CEA level on this patient. This patient has significant cardiac history and needs to be evaluated by a cardiologist prior to proceeding with elective major abdominal operation.

PREOPERATIVE DIAGNOSIS:
Status post Hartmann procedure for colonic perforation.

POSTOPERATIVE DIAGNOSIS:
Status post Hartmann procedure for colonic perforation with perforation noted at the rectosigmoid junction.

OPERATION PERFORMED:
1.  Hand-assisted closure of colostomy.
2.  Extensive lysis of adhesions.
3.  Lower anterior colon resection, especially that of proximal rectum.
4.  Cystoscopy with insertion of bilateral ureteral stents.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

DRAINS:  Placed a 10 mm Jackson-Pratt in the pelvis. Anastomosis completed with 25 mm circular stapler.

DESCRIPTION OF OPERATION:  The patient was first given general endotracheal anesthesia and then was prepped and draped in the usual sterile fashion for cystoscopy. The cystoscopy was done with insertion of bilateral 6 French ureteral stents without difficulty. When this was completed, the patient was then prepped and draped in the usual sterile fashion for laparoscopy and possible laparotomy.

An elliptical incision was made encompassing the prior colostomy site. The colostomy site was excised revealing extensive intra-abdominal adhesions, approximately the next 45 minutes to 1 hour taking down adhesions in an open fashion, freeing the abdominal wall and freeing numerous loops of bowel to allow access for placement of Lap Disc. Once the abdominal wall was cleared, Lap Disc was inserted in the left lower quadrant incision.

A 5 mm supraumbilical port was placed and 5 mm right upper quadrant port was placed. Adhesions continued to be taken down off the abdominal wall in a laparoscopic fashion with the abdominal adhesions, pelvic adhesions, and interloop adhesions. With the use of hand-assisted laparoscopy, the bowel was cleared out of the pelvis and revealed a rectal stump.

At this point, the rectal stump was sized upon the introduction of the 25 mm sizer. Feculent material exuded from an obvious perforation at the rectosigmoid junction. The dilator was removed and a 12 mm port was then placed in the right lower quadrant. At this point, the entire mesentery to the remaining proximal rectum was divided with the use of Harmonic scalpel down to clearly leave a cuff of normal colon distal to the obvious perforation.

At this point, the lower rectum was transected approximately 4 cm and the rectum proximal and mid rectum were delivered as specimen. At this time, the proximal colon was brought out through the Lap Disc. The proximal colon was markedly atrophied and sized to only contain a 25 mm stapler anvil. The entire left colon was then mobilized up and around to the splenic flexure. The left colon easily came down to the pelvis. An end-to-end anastomosis was then created with 25 mm stapling device.

Rigid sigmoidoscopy was then easily performed and revealed no leaks at the anastomosis. A 10 mm Jackson-Pratt was left in the pelvis. The abdomen was irrigated. Hemostasis was perfect in all dissection planes. Lap Disc incision was closed in layers with 0 Vicryl and then left opened with #2 nylon horizontal mattress for delayed primary closure.

A 10 mm Jackson-Pratt was placed through the right lower quadrant incision and sutured the skin with 2-0 nylon and the remaining two incisions were closed with 4-0 nylon in subcuticular manner. The patient tolerated the procedure well and was sent back to recovery room condition in stable condition.

PREOPERATIVE DIAGNOSIS:  Colon cancer.

POSTOPERATIVE DIAGNOSIS:  Colon cancer.

OPERATION PERFORMED:  Laparoscopic right hemicolectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

SPECIMENS:  Right hemicolectomy.

ESTIMATED BLOOD LOSS:  Less than 200 mL.

DRAINS:  None.

DESCRIPTION OF OPERATION:  After the patient was consented for laparoscopic right hemicolectomy, the patient was taken to the operating room and given general endotracheal anesthesia. He was placed in the supine position. A Foley catheter was placed. The abdomen was prepped and draped in the standard surgical fashion. Incision was carried down in the umbilicus approximately half inch in length with the use of a scalpel. A Veress needle was introduced. The abdominal cavity was insufflated with CO2 gas.

Next, 12 mm bladeless trocar was introduced into the abdominal cavity with ease. The abdominal cavity was then reinsufflated. A 10 mm, 30 degree scope was placed in the abdominal cavity. There was no evidence of any injury from the Veress needle or trocar. An additional 5 mm trocar was placed in the suprapubic position after a small stab incision was created with a 15 blade. This was placed under direct visualization and the exact same procedure was carried out with a 5 mm trocar in the left flank.

Upon inspection of the abdomen, the patient was noted to have a large mass at the hepatic flexure, also noted to have a large mass at the distal appendix. The mass was noted to extend under the liver bed, which was densely adherent to the liver. Next, the ileocolic artery was identified and taken with the use of the Ace Harmonic scalpel. The retroperitoneal dissection was carried up to the level of the hepatic flexure. Following that, the terminal ileum was mobilized and the right paracolic reflections were taken down along the line of Toldt with the use of the Ace Harmonic scalpel.

Using an additional 5 mm trocar, which was placed up in the left upper quadrant after a small stab incision was created, the liver was retracted superiorly and the attachments of the transverse colon were taken down with use of sharp dissection. The omentum was taken off of the transverse colon to the level of the mid transverse colon. The right colic artery was identified and taken with the use of the Ace Harmonic scalpel. The duodenum was identified and mobilized medially.

Once the colon was completely mobilized to the level of the mid to distal transverse colon, the 5 mm trocars were removed. The terminal ileum was grasped with a grasper, and the incision through the umbilicus was extended to approximately 3-1/2 inches in length with the use of cautery. A retractor was placed into the wound.

The bowel, including the terminal ileum, right colon and transverse colon, were brought up through the incision. The terminal ileum, approximately 15 cm proximal to the ileocecal valve, was transected with a 75 GIA stapler and the mid transverse colon was transected in a similar fashion. The mesentery was taken with the use of Ace Harmonic scalpel. The specimen was passed off the field, labeled as right colon, and there was noted to be a large mass with several large lymph nodes adherent to it.

Next, a functional side-to-side anastomosis was created with a 75 GIA stapler followed by closure with a TA60. The created anastomosis was reinforced with 3-0 Vicryl pop-off interrupted. The staple line was reinforced with 3-0 Vicryl pop-off interrupted in a Lembert fashion. The bowel was then returned to the abdominal cavity. The omentum was draped over the bowel. The abdomen was then copiously irrigated. There was no evidence of any bleeding. A sheet of Seprafilm was placed in the abdominal cavity.

The fascia was approximated with #1 PDS in a running fashion. Subcutaneous tissue was copiously irrigated and the skin was approximated with staples. The trocar sites were approximated with staples as well. The abdomen was cleaned and dried. Dry sterile dressings were applied. The patient was awakened, extubated, and transported to the recovery room alert, awake, and in stable condition. All sponge and instrument counts were correct at the end of the case.