Date of Surgery -
Preop Diagnosis - perforated colon
Postop Diagnosis - same
Surgeon - Dr. Luk / Dr. Tran
Assistant Surgeon -
Anesthesia - General
Blood Loss - Minimal
Complication - None
Findings - Perforated colon
Specimens - Sigmoid Colon
Indication- Perforated Colon
Procedure performed:
Sigmoid resection with diverting colostomy - i.e. Hartmann's Procedure
Take down of splenic flexure
Lavage of abdominal puss and contamination
Incidental appendectomy
Placement of tunneled intra-abdominal drain
Patient comes in with the above diagnosis and was consented for the above procedures. Risks, benefits, and alternatives were discussed with patient, which includes, but are not limited to, postoperative or chronic pain, bleeding, wound infection, hematoma, post-operative abscess, incision disruption, injury to other organs, or need for further procedures or workup. Other complications may include deep vein thrombosis(blood clots), as well as other side effects affecting other organ systems such as the heart or lungs, and in rare circumstances, death as a result of the above complications. The patients understands and agreed that a colostomy for fecal diversion may be needed. The patient understands and agrees to proceed with the proposed procedure.
After consent was obtained, the patient was brought to the OR and underwent general anesthesia. The patient was prep and draped in the standard manner.
The patient was given preoperative antibiotics.
Timeout was performed and all was in agreement.
A standard midline incision was performed using 10. Scalpel. Dissection down to the fascia using electrocautery. The fascia was opened. Once we entered the abdominal the abdominal retractor was placed for exposure.
Headlight were used for proper illumination
The patient has sigmoid diverticulitis with perforation
There is heavy abdominal contamination. The suction irrigation device was used to lavage removed contamination.
Findings here.............................................
Mobilization was performed mainly using blunt dissection to separate the sigmoid colon and rectum from the pelvic sidewall.
Next, the upper left colon was taken down using the electrocautery along the left line of Toldt
This was performed starting at the mid sigmoid and working up towards the healthier proximal sigmoid.
The splenic flexure was taken down to help increase the length and mobilization for the colostomy.
This was done using the electrocautery as well as the ultrasonic scalpel.
The GI stapler was used to divide the bowel proximal and distal to the disease bowel.
Rectal stump was marked with a blue permanent suture for later re-anastomosis.
Because of the patient condition and the severe contamination, a decision was made to perform a diverting colostomy for now.
A circular skin incision was made on the patient’s left lateral abdominal wall.
This was done using 10. Scalpel.
Dissection was carried out down to the fascia.
Fascia was opened and a muscle-splitting technique was performed to enter the abdominal cavity through the small opening.
The proximal end of the sigmoid colon was brought out through the small opening.
Before maturing the colostomy, the abdominal cavity was irrigated with copious amount of saline.
The saline was removed
I irrigated the abdominal cavity until all the fluid was clear.
Incidental appendectomy if done ______________________________________
The clinical decision was made to remove the appendix since any future surgery for appendectomy may be complicated by adhesions and may not be achievable by laparoscopic method.
The appendix was identified, the mesentery was mobilized. The base of the appendix was divided using a GI stapler.
The appendix was passed off as specimen.
One JP drain was tunneled and positioned intra-abdominally under direct vision.
Closure
Before closure, we examined the operative field carefully. Hemostasis was completely obtained. There were no injury to the other organs seen.
Finally, we changed gowns and gloves
At the end of the case, counts were carried out. When instrument, sponge, and needle
counts were completed and reported to me as correct, then I began the closure.
The midline fascial incision was closed using running looped PDS suture. The skin was stapled.
The colostomy was matured using 3.0 Vicryl suture.
The patient tolerated the procedure well. At the end of the case, all instruments, sponge, and needle counts were reported to me as correct. The patient was transferred to the recovery room in stable and satisfactory condition.