DATE OF OPERATION: MM/DD/YYYY
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.
