DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Gallbladder mass.
2. Enterocolonic fistula.
POSTOPERATIVE DIAGNOSES:
1. Gallbladder mass.
2. Duodenojejunal fistula secondary to Crohn disease.
3. Ileocolonic fistula secondary to Crohn disease.
OPERATIONS PERFORMED:
1. Open cholecystectomy with intraoperative cholangiogram.
2. Small bowel resection with stapled side-to-side functional end-to-end anastomosis.
3. Takedown of duodenojejunal fistula with stapled repair.
4. Takedown of ileosigmoid fistula with two-layer primary closure.
5. Lysis of adhesions.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General anesthesia combined with endotracheal tube intubation.
SPECIMENS:
1. Ileocolonic fistula with matted segment of small bowel contents.
2. Gallbladder.
3. Fistulous tract from the ileosigmoid region.
4. Fistulous tract from the duodenojejunal tract.
COMPLICATIONS: None.
DRAINS: A 15-French round JP drain placed within the gallbladder bed fossa after completion of cholecystectomy.
ESTIMATED BLOOD LOSS: Approximately 700 mL.
INTRAOPERATIVE FINDINGS: Upon entry into the peritoneal cavity, we first directed our attention to performing the cholecystectomy. A hard nodular mass could be easily palpated and appreciated within the fundus of the gallbladder. There was no evidence of transmural infiltration of this mass through the gallbladder wall nor into the liver parenchyma. There was no evidence of lymphadenopathy within the porta hepatis.
We then turned our attention to the ileocecal region, and there was a large area of matted small bowel with numerous fistulous tracts. Once we were in the small bowel from the ligament of Treitz to the ileocecal region, we were also able to identify additional fistulous tracts, one being from the fourth portion of the duodenum to the proximal jejunum and another one being present from the terminal ileum to the sigmoid colon.
Multiple adhesions were also sharply and bluntly lysed during the course of our dissection in removal of the small bowel with its numerous fistulous tracts. The right and left ureters were not injured during the course of our dissection. No other abdominal pathology was noted. It should be noted that there were no mesenteric abscesses found during the course of our dissection secondary to her Crohn disease. Mesenteric fat creeping was also evident within the small bowel mesentery within the terminal ileum.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic female who has had a significant past medical history for Crohn disease, which has been clinically managed with medical therapy. It seems that for the past couple of months, the patient has had multiple GI complaints, mostly diarrhea with intermittent episodes and unable to be controlled. The patient presented to the hospital with this complaint in addition to some nausea and vomiting. Workup eventually led to a surgical consultation along with a gastrointestinal consultation.
During the course of her preoperative workup, a small bowel series was obtained, which revealed an enterocolonic fistula. The patient was then placed upon hyperalimentation to increase her nutritional status prior to surgical intervention and removal of this fistulous tract. A CT of the abdomen and pelvis revealed a gallbladder mass. It was explained to the patient and family that an open cholecystectomy along with removal of the fistulous tract would need to be performed. All of the risks, benefits, and alternatives of the procedure were described in detail to the patient and family. The patient along with her son were in agreement and agreed to proceed with surgical intervention.
Preoperative antibiotics were given. IV fluid resuscitation had been performed, and the patient’s nutritional status has slightly improved from an albumin of 7.4 to 11.2 prior to surgery. Preoperative consent was signed and placed upon the chart.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the supine position. Bilateral lower extremity athrombics were placed. General endotracheal anesthesia was then induced. A Foley catheter along with a nasogastric tube were placed. The abdomen was then prepped and draped in the usual sterile fashion.
A vertical midline incision was then made from the xiphoid to just below the umbilicus. This was then deepened through the subcutaneous tissues, and hemostasis was achieved with electrocautery. The linea alba was identified, incised, and the peritoneal cavity entered. The abdomen was explored. The falciform ligament was doubly ligated with 2-0 silk and divided. We then placed traction on the fundus of the gallbladder. An attempt was then made to identify the cystic artery and cystic duct and Calot’s triangle. These were identified and ligated but not divided at this time.
The peritoneum overlying the gallbladder was then incised circumferentially from cephalad to caudad, and the gallbladder was then shelled out of its bed for the top down until the structures of Calot’s triangle could be delineated with certainty. A nick was then made in the cystic duct, and a Ranfac catheter was then threaded.
An angiogram was obtained that showed good flow into the duodenum with an intact biliary tree and absence of any filling defects. The cystic duct and cystic artery were then ligated with 3-0 silk, and the proximal sides were also done in the same manner along with additional hemoclips. The gallbladder at this time was then removed and passed off the table as a specimen. Hemostasis was checked, and the hepatoduodenal inspected and found to be intact without any palpable abnormalities. At this time, we had to continue to utilize Bovie electrocautery along with some Surgiflo and also some Surgicel along with packing with lap sponges to maintain hemostasis.
At this time, we went ahead and proceeded with identifying the inner colonic fistulas that were present on preoperative workup from the patient’s Crohn disease. There was a large amount of small bowel that was present within the terminal ileal region to the cecum that seemed to have fistulous communications. While examining the portion of the small bowel, as we ran it from the ligament of Treitz to the distal ileocecal region, we were able to note that a duodenojejunal fistula was also present along with an ileosigmoid fistula.
At this time, we went ahead and divided the fistulous tract between the ileum and the sigmoid colon. Very minimal bowel contents were spilled. The defect present within the sigmoid colon was then closed in a two-layer fashion using a chromic to perform the inner layer and then the outer layer was imbricated with 3-0 silk sutures in a Lembert fashion. Palpation of the sigmoid colon thus creating increased intraluminal pressure did not show any leakage of bowel contents.
Once this was performed, we then directed our attention at performing lysis of adhesions within the terminal ileal region, and we were also able at this time to identify an ileal to ascending colon fistula along with a duodenojejunal fistula. A full kocherization maneuver was performed.
We next identified our points of transection proximally and distally, and these were transected with a 75 mm GIA stapling device. We utilized green tissue loads for both transections. The proximal point of transection was within the terminal ileum and the distal transection point was in the mid ascending colon. Once these points of transection were identified, the mesentery was then scored and taken down between 2-0 silk sutures, which were then ligated and divided. This portion of the specimen was then passed off the table and sent to pathology.
We then, at this time, measured the ligament of Treitz to the remaining portion of small bowel which totaled 180 cm. Prior to performing our ileocolonic anastomosis, we then repaired the fistulous tract that had been created between the duodenum and a portion of the small bowel had already been removed en bloc. The duodenal defect, which was present within the fourth portion of the duodenum, was repaired with a TA 60 stapling device, and this was then oversewn with multiple sutures of 3-0 silk in a Lembert fashion. The lumen was easily patent.
We then performed a side-to-side functional end-to-end stapled anastomosis with GIA stapling device. All portions of the small bowel were shown to be viable at each one of our repairs along with our new anastomosis. The mesenteric bed was shown to be hemostatic, and the mesenteric rent was closed with figure-of-eight 3-0 silk sutures. The abdominal cavity was then copiously irrigated with warm Kantrex solution, approximately 2 liters. This was then siphoned free. A 15 French round JP drain was then placed within the gallbladder bed fossa and exited out through the right upper quadrant and then anchored in place with a 3-0 silk suture and hooked to bulb suction.
At this time, we asked Anesthesia to go ahead and migrate the nasogastric tube into the stomach and this was easily palpated. The anterior fascia was then closed with a running suture of 1-0 Prolene. Subcutaneous tissues were irrigated. Incision was then reapproximated with skin staples. The incision was then cleaned and dried along with application of a sterile dressing. The patient was then taken to the recovery room in stable condition. All instrument, sponge, and needle counts were correct at the end of the case.
