OPERATION: Abdominoperineal resection with prominent left lower quadrant colostomy.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, placed on the operating room table in supine position. General endotracheal anesthesia was performed. The patient's legs were placed up in Allen stirrups. A Foley catheter was inserted using the aseptic technique. A rectal washout was then performed by inserting a 22-French Foley catheter inserted in the patient's rectum. The balloon was then inflated. The rectum was then irrigated out with sterile water and Betadine solution until clear. The balloon was then deflated and the Foley was removed out of the rectum. The patient's abdomen was then shaved, prepped, and draped. Using the aseptic technique, a central line was subsequently placed by Anesthesia, as well as insertion of NG tube. The patient's perineal area was prepped as well.
Attention was then turned to the patient's lower abdomen. Incision was made from symphysis pubis to umbilicus, midline. The incision was carried down through the dermis, subcutaneous fat, and linea alba using electrocautery. Preperitoneal fat was incised using electrocautery. Peritoneum was grasped with pickups. Small incision was made in the peritoneal cavity. The preperitoneal fat and peritoneum were then incised along the length of the incision. The abdominal cavity was then explored, beginning with the stomach and duodenum. NG tube was felt to be in adequate position. The left lobe and right lobe of the liver were palpated and felt to be normal. The right colon, transverse colon, and descending colon were palpated and felt to be grossly normal as well. Sigmoid colon was markedly redundant. A Bookwalter retractor was then placed on the operating room table and used for retraction throughout the procedure.
Attention was then turned to the sigmoid colon. The lateral attachments were freed up using electrocautery. Left ureter was identified in the left retroperitoneal space. A site was chosen in approximately the proximal sigmoid colon for proximal wide resection. This was determined by placing the rectum, sigmoid on stretch. A hemostat was then introduced between the mesentery and the bowel wall. The ligature was then used to ligate the mesentery up to the vascular pedicle. Pericolic fat and mesentery immediately around the bowel wall was freed up using electrocautery. The pursestring device was then brought into field, placed across the colon at that point. Kocher clamp was placed distally. Noncrushing bowel clamp was placed proximally, then severed between the two. The pursestring device was then removed leaving the pursestring in place. The bowel limb was then opened with Babcock clamps, with Betadine soaked 4 x 4. A 29 EEA stapler was brought into the field. The limb was then inserted into the proximal colon and pursestring was tied. This was then tacked off in left upper quadrant.
Attention was then turned back to the sigmoid colon. The mesentery was high ligated, doubly clamped, with 2-0 silk double ligatures proximally, one distally. The sigmoid colon was then reflected inferomedially. The perineum on either side of the sigmoid colon and rectum was incised and then anteriorly on the cul-de-sac of Douglas. The sigmoid colon was then reflected inferiorly, medially. Dissection was carried out over the presacral space and avascular space down to Waldeyer fascia. Waldeyer fascia was incised using electrocautery. The lateral ligaments were taken down using electrocautery. The presacral nerves were visualized and appeared intact throughout the procedure.
Anteriorly, dissection was carried down through the Denonvilliers fascia. Posterior Waldeyer fascia was incised. Levators were visualized on either side of the rectum. Dissection was carried down until the rectum was visualized and meeting out to the levator muscles circumferentially. The tumor was palpable within the rectum and extended all the way down to the levator muscles. It appeared that a distal margin would not be obtainable. At this point, I elected to proceed with abdominoperineal resection.
Attention was then turned to the patient's perineum. A 0 Prolene suture was used for pursestring around the anus. An elliptical incision encompassing the anus was then performed using a scalpel. Hemostasis controlled using electrocautery. The Lone Star retractor was brought into the field and used for retraction. The stays were placed circumferentially in the skin. Dissection was carried out posteriorly through the anococcygeal ligament. Access was gained into the perineal cavity, above the sacrum. The levator muscles on either side were incised using the ligature. Anteriorly, the dissection was carried out through the transverse perineal muscle. The proximal sigmoid colon was then delivered posterior to the anus. The main portion of the rectum and anus was excised using electrocautery from the remaining levator sling complex. Specimen was then placed on the back table, opened, and appeared to be adequate resected margin, including radial, without evidence of involvement grossly of the rectal wall or surrounding tissue. Hemostasis controlled using electrocautery. The pelvis, perineal portion was then irrigated out with sterile water. Good hemostasis noted.
Closure of the peritoneal wound was then begun approximating the levator muscles from posterior to anterior with 2-0 Vicryl interrupted sutures. Subcutaneous tissue was approximated using 2-0 Vicryl interrupted sutures. The skin was approximated using 3-0 nylon vertical mattress sutures. The wound was then cleansed and dried, and sterile dressing was applied.
Attention was then turned back to the abdominal cavity and perineum. A site was chosen in the left lower quadrant for the ostomy site, which had been previously marked by Enterostomy Therapy. The skin was grasped with Kocher clamp. An oval incision was made using the scalpel. The subcutaneous fat was incised in conical fashion down to the anterior rectus sheath. The anterior rectus sheath was incised in a cruciate fashion. The rectus muscle was separated. The posterior perineum was incised using electrocautery. The transected sigmoid colon, with the anvil in place, was then delivered out of the ostomy site. The mesentery above the skin area was incised using electrocautery down to the colonic wall. A 10 Blake drain was then inserted through a stab wound in the right lower quadrant, placed in the pelvis. The perineum was approximated to the midline over the pelvis with 3-0 Vicryl running continuous suture. The Blake drain was sutured to the skin using 2-0 silk. All packs and retractors were then removed. Seprafilm was placed in the pelvis over the approximated perineum, over the omentum anteriorly.
Closure was then begun by approximating linea alba from the umbilicus down and from the symphysis pubis up with one looped PDS running continuous suture. Hemostasis controlled using electrocautery. Wound was irrigated out with sterile saline. Good hemostasis noted. Skin edges were approximated using skin staples.
Attention was then turned to the ostomy site. The redundant sigmoid colon was excised using electrocautery. The ostomy was matured with absorbable suture. The wound was then cleansed, dried around the ostomy site. Benzoin followed by ostomy appliance bag was applied with clip. Sterile dressing and tape were applied to the midline incision. The patient was then taken out of Allen stirrups, extubated, and transported to recovery room in stable and satisfactory condition.
OPERATION: Colonoscopy to the cecum.
DESCRIPTION OF PROCEDURE: The patient was taken to the outpatient endoscopy suite where he was monitored for pulse oximetry and blood pressure monitoring. He was turned to the left side and given 50 mg of Demerol with 2 mg of Versed, titrated during the procedure. An Olympus video colonoscope was inserted in the patient's anus and directed up to the rectum, sigmoid colon, descending colon, around the splenic flexure, through the transverse colon, around the hepatic flexure, ascending colon, and cecum. The ileocecal area was inspected and appeared grossly normal. Terminal ileum was cannulated, appeared grossly normal. The scope was then slowly withdrawn back through the entire colon, rectum, and anus and no gross abnormality or lesion was identified. Mucosa pattern appeared normal. The patient tolerated the procedure well. He will be discharged home with instructions to follow up for a surveillance colonoscopy.
PREOPERATIVE DIAGNOSIS: Hemorrhoidal prolapse.
POSTOPERATIVE DIAGNOSIS: Hemorrhoidal prolapse.
OPERATION PERFORMED: Stapled hemorrhoidopexy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ESTIMATED BLOOD LOSS: Minimal.
POSTOPERATIVE CONDITION: Good.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the prone jackknife position after spinal anesthetic had been given. Buttocks were then taped apart and the perineum prepped and draped in sterile fashion. A digital rectal exam and anal inspection confirmed hemorrhoidal prolapse; therefore, an obturator and dilator with PPH 03 stapler was advanced into the anal canal and obturator secured with 0 Ethibond. An operating anoscope was then used to place the submucosal circumferential 2-0 Prolene purse-string suture. The purse-string was tested and noted to be intact. Gentle vaginal exam revealed no incorporation of the posterior vaginal wall. The stapler was then brought into the anal canal above the purse-string with the anvil fully opened and the purse-string was tied. The threads of the anvil were then closed to shorter staple height with traction on the sutures, which have been brought through the head of the stapler. About 30 seconds was allowed to be elapsed and the stapler was fired. The stapler was then removed. There was noted to be hemostatic staple line above the dentate line, which showed no evidence of bleeding. This area was thoroughly irrigated. The obturator was removed. The area was once again inspected and noted to be free of bleeding, and therefore, the patient was flipped back supine and taken to recovery in good condition.
OPERATION: Excision of fistula-in-ano.
DESCRIPTION OF PROCEDURE: The patient was placed in the supine position under general LMA anesthesia. The patient was placed in the lithotomy position, and the perianal area was prepped and draped in the usual sterile manner. The opening to the exterior had closed, and using a scalpel, it was opened. There was some fluid and pus that drained. The lacrimal duct probe was placed into the tract and it easily went through the internal opening of the fistula. Both ends of the lacrimal duct probe were held, and the fistula-in-ano was excised with the cautery. Hemostasis was achieved with the cautery. A 4 x 4 was impregnated with KY Jelly and part of it was placed into the rectum. The other part was used as a pressure dressing over the wound. A 4 x 4 was placed over that and taped in place. The patient tolerated the procedure well and was taken to the recovery room in good condition. Estimated blood loss was 2 mL.
OPERATION: Flexible sigmoidoscopy to splenic flexure with snare polypectomy of pedunculated polyps of sigmoid colon and hot biopsy of rectal polyps x1.
DESCRIPTION OF PROCEDURE: The patient was taken to the outpatient endoscopy suite where she was monitored with pulse oximetry with blood pressure monitoring. She was turned to the left side and given 50 mg of Demerol with 4 mg of Versed. Olympus video colonoscope was then placed in the anus and directed up to the rectum, sigmoid colon, descending colon and to the splenic flexure. The scope was then slowly drawn back. In the sigmoid colon, marked diverticular disease was noted. The polypoid lesion was identified, and using snare polypectomy technique, it was removed. The scope was then withdrawn back into the proximal rectum where a sessile polyp, 0.5 cm in size, was visualized and was hot biopsied. The polyp, which had been snared, was sucked up within the scope and retrieved as the scope was removed out of the rectum and anus. This will be sent to pathology as well as the biopsy polyp. The patient will be followed up in the office.
OPERATION: Exploratory laparotomy, repair of colotomy, and end-colostomy.
DESCRIPTION OF OPERATION: The patient was brought into the operating room and placed on the operating room table in supine position. Following the induction of general anesthesia, the abdomen was prepped and draped in the usual sterile fashion. Standard midline incision was made with a #10 scalpel blade, deepened through the subcutaneous tissue with electrocautery. Following this, the fascia was incised and abdominal cavity was entered. A large amount of serous fluid was then aspirated from the abdominal cavity. There was no evidence of frank pus or feculent material in the abdominal cavity. The bowel was then run from the ligament of Treitz to the ileocecal valve and found to be normal. There was no evidence of gastric perforation upon inspection of the colon. Small area in the left lower quadrant was found to have the most inflammatory response. It was felt that this was the area with small perforation, which had seated the peritoneum resulting in peritonitis. It was thus elected to perform a diverting colostomy from this region. Suitable area was identified. The splenic flexure was taken down in order to mobilize the colon further. The colon was encircled. Mesentery was divided between clamps and ligated with 2-0 silk sutures. The colon was then transected. A TIA 55 stapler was placed across the proximal margin and fired. The bowel was then opened and the distal limb was then flushed with methylene blue and a small hole in the colon, in the left lower quadrant, was identified in the area that had been previously suspected of having a leak. This was then repaired with interrupted sutures of 3-0 silk. Following this, no leak was noted. The opening was then closed with a TIA 60 stapler. Next, the abdomen was copiously irrigated and appropriately suctioned. The ostomy was brought out through a fascial incision in the left abdomen. The midline fascia was then closed with interrupted figure-of-eight sutures and subcutaneous tissue was irrigated. Skin was closed with staples. The ostomy was then secured to the skin with 3-0 chromic sutures. Sterile dressings were applied. The patient tolerated the procedure and was transferred to the recovery room in guarded condition.
1. Resection and closure of anal/pouch vaginal fistula via perineotomy.
DESCRIPTION OF OPERATION: The patient was brought to the operative suite and placed supine on the operating table. After adequate general endotracheal intubation was performed and the patient was safely asleep, she was rolled gently into the prone jackknife position with the appropriate padding underneath the chest, hips, and ankles. All bony prominences were padded to prevent damage during the case. A breast roll was placed beneath her breasts to both elevate her breasts and to pad them without pressure. The patient was then placed in a flexed position. Her buttocks were spread and skin taped to view the anovaginal area. Bair Hugger was used for warming.
Once confirmed that the patient was stable and asleep in this position, the perineal and the vaginal area were prepped and draped in a sterile fashion with povidone-iodine solution. Under sterile conditions, the anatomy was reviewed. There were two existing setons in the anovaginal fistula. These setons were viewed.
The planned inverted semicircular incision was drawn at the anterior circumference of her anal canal, to the left lateral position. This was drawn through the perineal body. This incision was made, carrying it down through the subcutaneous tissue. Dissection was then performed to dissect off the sphincter components, dissecting in the anovaginal space, dissecting around to the vaginal portion of the fistula. The dissection, anterior to the anus, was then dissected out to the portion of the anterior internal opening. The sphincter muscle "in front" of the fistula site was then isolated and then divided with electrocautery in the midline. This effectively opened up tissues down to the existing fistula site. The fistula site was then disconnected by dissecting both the anal components away and also dissecting the vaginal components away. This was performed first by mobilizing the sphincter components, that being the external sphincter anteriorly and posterolaterally bilaterally.
The inflamed fibrotic portions of the internal sphincter, which were involved with the fistula site, were also dissected, finding the intersphincteric groove where the apex of the original abscess cavity, adjacent to the anal canal, was found. In dissecting out the internal sphincter, the fistula itself was completely removed in toto along with the setons. At this time, having defined the components, not only of the anal canal all the way up to the dentate line where the defect was located, we also identified the proximal defect of the vagina. We also had isolated the proximal defect of the internal sphincter.
At this time, a Ferguson retractor was placed within the anal pouch canal. There was some tethering here. Therefore, rotational flap of the anoderm, on the right side, was rotated internally to enlarge the anal opening, suturing the anal canal mucosa actually to the anorectal mucosa at the pouch site, enlarging this opening in a radial fashion. This was approximated with #4-0 Vicryl. There was adequate redundant perianal tissue to accomplish this rotational flap for future repair of the perianal skin. Having repaired the anal canal, attention was diverted to repairing and imbricating the internal sphincter components which was performed creating a good buttressing of tissue of the anal canal between the anal canal mucosa and the vaginal mucosa. This also effectively lengthened the anal canal as it had been shortened by the fibrotic effects of the fistula.
Finally, the previously mobilized sphincter components were drawn together in an overlapping fashion. Mayo type sutures using #0 Maxon was used to perform an overlapping sphincteroplasty, with horizontal mattress sutures. The overlapping sphincter components that had thus been formed were also ________ to the lateral aspect of the sphincter in the same fashion creating two contralateral suture lines of the overlapping sphincter repair. This effectively interposed good vascularized tissue between the original pouch-anal area and the disrupted vagina. Finally, the vaginal opening was freshened by excising the edges and the old fistula site. This was then repaired with interrupted #4-0 Vicryl sutures.
All that was left was to close the soft tissues. This was performed in the V-to-Y fashion with the vertical limb of the Y at the apex of the posterior fourchette and the edges of the Y at the lateral aspects at the anal canal. This was performed in an interrupted fashion with #4-0 Vicryl suture, starting at the long limb of the Y. The Y components were repaired with interrupted vertical mattress sutures of nylon. Where the two limbs of the Y came together, the original anoderm was repaired in an interrupted fashion thereby closing the defect completely. Prior to closing completely the soft tissue, a small 1/4-inch Penrose drain was brought up though the long limb of the Y incision for drainage. It must be noted that the proctoplasty/anoplasty portion of this procedure was performed with a #16 Hegar dilator within the anal outlet thereby being sure of a #16 French lumen of the proctoplasty/anoplasty component.
A #18 Malecot was placed within the pouch and brought through the anal opening for drainage and decompression of the pouch. The vagina was packed with antibiotic-impregnated vaginal gauze. Sterile soft dressings were applied over the incision repair, which was held in place with ARD pad. The patient was then rolled back into supine position. A Foley catheter had been placed earlier and was draining clear urine. The patient was then extubated and transported to the recovery room.
1. Colonoscopy with polypectomy x2 using a snare.
I then used a solution of 0.5% Marcaine with epinephrine and injected about 25 mL perianally and intramuscularly to achieve relaxation of the sphincter muscles. I could see a small scar posteriorly about 2 to 3 cm from the anal verge, where the external opening had been. It was closed at this time. I then inserted a small Ferguson retractor into the anus and noted what appeared to be an old fissure in the posterior position. I then used a crypt hook and was able to identify a little bit of tracking posteriorly. This area was unroofed. I then used a 15 blade scalpel to make an incision through the scar where the external fistula opening had been and gently used an S-shaped fistula probe to probe this area. Again, I was able to get some tracking toward the posterior anal canal and I unroofed this. However, there was about a centimeter of tissue where I was not able to identify a definite tract. I did not want to force the probe through and create a tract. I then used some hydrogen peroxide and used a 20 gauge IV catheter to inject this first into the external opening and then into the internal opening, but I was not able to identify peroxide coming through any definite tract. Because I could not find a definite tract to complete the fistulotomy, I simply left the two openings unroofed. I then used 4-0 Monocryl suture to marsupialize the skin edge down to the base of the tract, externally, on both sides and then internally marsupialized the anoderm down to the base of the muscle.
I then directed my attention anteriorly. The Chelsea-Eaton retractor, which had been used, was then replaced to expose the right anterior position. The retractor was then removed and a marking pen was used to outline the external tag. It did not continue into the anoderm level. It was then excised using Potts-Smith scissors. The base was coagulated to control small amount of bleeding and then the skin edges were brought together in a running fashion using the 4-0 Monocryl suture. At this point, we had good hemostasis throughout. A rolled Gelfoam was placed in the anal canal and the procedure was terminated. The patient was awakened, returned to the supine position and taken to the recovery area in stable condition.
OPERATION PERFORMED: Right hemicolectomy.
DESCRIPTION OF OPERATION: After appropriate preparation, signed informed consent, the patient was brought to the operating room, prepped and draped in the supine position. Under satisfactory endotracheal anesthesia, Foley catheter and NG tube were inserted. A midline incision was utilized, carried down to the subcutaneous tissue. The linea alba was split with a scalpel. The abdomen was entered in the usual fashion obtaining hemostasis in the subcutaneous tissues. Exploration revealed a normal liver and gallbladder. The colon was mobilized with a retractor along the right side, along the right colic gutter, using the ACE Harmonic scalpel. We divided the hepatocolic ligament and entered into the lesser sac and took the dissection down to the mid transverse colon, entering the lesser sac. At this juncture, the ileum was also freed up by dissecting and freeing up its attachments to the lateral wall. The terminal ileum was brought up into the wound and a little otomy was made in the mesentery of the transverse colon and the GIA was fired across it dividing the transverse colon. Next, using the ACE Harmonic scalpel, we took down the mesentery and its vessels. Larger vessels were clamped with Kelly clamps and tied with silk suture material. We took this all the way up to the terminal ileum and then divided the terminal ileum with a GIA. With the specimen off the table, we opened it up on the back table and found several scattered flat polyps, none of which appeared to be ominous. A standard anastomosis was then made between the terminal ileum and the transverse colon in a side-to-side fashion using the GIA and TA60. Lembert sutures of 3-0 silk were placed in the dependent portion of the anastomosis and the crotch of the anastomosis and then the mesentery was closed with running locking suture of 3-0 Vicryl. Right colic gutter was copiously irrigated with saline solution. Omentum was brought back down over the anastomosis. Small bowel was placed back in its normal anatomical position. The area was checked for hemostasis and irrigated with saline solution. Two layers of Seprafilm were placed in the abdomen over the omentum. The abdomen was closed with running suture of #1 PDS from above and below. The skin was closed with stainless steel staples. Dry sterile dressing was placed on the wound. The patient tolerated the procedure well and left the operating room in good condition.