DATE OF OPERATION: MM/DD/YYYY
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.
