Procedure(s):
COLOSTOMY REVERSAL IN STIRRUPS
Lysis Of Abdominal Adhesions
Small Bowel Resection
Loop Ileostomy Open Procedure Note
Pre-op Diagnosis:
Tobacco use disorder [F17.200]
Adenocarcinoma of colon (HCC) [C18.9]
Colostomy in place (HCC) [Z93.3]
Post-op Diagnosis: SAME
CPT Code: Procedures:
* COLOSTOMY REVERSAL IN STIRRUPS 44626
* Lysis Of Abdominal Adhesions, 44005
* Small Bowel Resection 44120
* Protective Loop Ileostomy Open 44310
* Mobilization of splenic flexure 44139
ICD-10 : Post-Op Diagnosis Codes:
* Tobacco use disorder [F17.200]
* Adenocarcinoma of colon (HCC) [C18.9]
* Colostomy in place (HCC) [Z93.3]
Findings: We are surprised to find exceedingly dense adhesions including densely adherent small bowel behind the thickened uterus, very difficult to release in the absence of direct visualization, once elevated we can find the small clips of the stapled rectum and blue Prolene sutures on either side. For the anastomosis ultimately I have to incise the posterior uterine peritoneum so that the circular EEA stapler can be palpated circumferentially. That anastomosis, 28 mm EEA, is tested with infusion of Betadine and saline and air without obvious leak. Because it was a tenuous and difficult dissection, I protect with a loop ileostomy in the right lower quadrant. Just distal to the ileal loop is an area of small bowel resection, this was the densely adherent small bowel down in the pelvis which had to lengthy of a serosal exposure to repair that a short section is removed with a side-to-side stapled anastomosis.
She had densely adherent small bowel in the left deep paracolic gutter which was very difficult to release, and then very difficult to separate from the and limb of colostomy. Once the colostomy was released with very difficult dissection and exposure, the terminal component is devascularized and relatively sharply demarcated, we picked slightly more proximal and this is essentially the redundant left descending colon which does reach into the pelvis and ultimately laid within the left retroperitoneum over the pelvic brim.
A serosal injury to the proximal small bowel at about 10 cm away from the ligament of Treitz, is repaired with transversely placed horizontal mattress 2-0 silk suture. Three other small serosal tear sites are closed in this fashion. There was no full-thickness injury of the small bowel. Ultimately the small bowel is re–run from ligament of Treitz to the ileocecal valve without unrepaired sites and good vascularization.
The left gonadal vein is very prominent and at one site over the pelvic brim this tears and is controlled with a running lock 2-0 silk suture. At the site more proximal, during dissection, a small opening is controlled with a 5-0 Prolene suture. Once elevated and slightly medial we find the left ureter both at the site of this repair and then down below the pelvic brim, uninjured.
The spleen is evident and uninjured, we released the splenic flexure exposing the anterior kidney but not the adrenal gland, and exposing the ligament of Treitz without injury of small bowel here. The previously dissected, at first operation, inferior mesenteric vessels are again identified with parallel staple lines, small bowel was densely adherent here and was part of the tedious lysis of adhesions but ultimately all small bowel defects repaired as described above.
The stomach is quite large for this small woman and a nasogastric tube palpated within. The gallbladder is soft and flaccid but very large and evident almost at the upper midline incision.
I palpate no liver lesions in the left lobe, the right lobe is blocked by adhesions and not dissected. The transverse colon is unremarkable. The bladder is unremarkable. The bilateral fallopian tubes are present, very small contracted ovaries. A thick uterus of unknown significance but not asymmetric.
After the abdomen is closed, and the stomal tunnel on the left is closed, the loop decompressive ileostomy in the right lower quadrant is matured to the edges in standard Brooke fashion.
We probably lose easily 300 mL’s throughout the course of the dissection, no hemodynamic instability.
Indications: She presented with an intussusception, that was a malignant T2N0 sigmoid but the intussuscepted segment was very low into the pelvis. There were no nodes involved. It has been nearly 5 months later and she presents for colostomy reversal, I did not anticipate adhesions.
Description of Procedure: In the supine position with appropriate monitoring she received general anesthesia with IV antibiotic, nasogastric tube was placed. Foley catheter catheters placed. She is placed in stirrups. I irrigate the vagina with dilute Betadine solution and then the rectum. Mucoid material is removed. Is difficult to palpate the proximal extent. Then the perineum is prepped with Betadine. I had removed the left lower quadrant stoma appliance and cleansed the skin and inverted with a pursestring suture using 2-0 Prolene, the stoma. The abdomen was then widely prepped with chlorhexidine and draped after 3 minutes. We enter above the previous supraumbilical incision and then open to the right and to the supra pubis through the old scar. She has a paucity of fat. The abdomen is entered above and then dividing through old scar. With Coker clamps elevating the fascia, the adhesions of small bowel to the left and right lower abdomen are taken down sharply. This is an extensive lysis of adhesions as presented above, easily 75% of the operating time. I used a combination of sharp scissor release or cautery adhesions could be transilluminated. Ultimately all the small bowel is released packed away, the ureter was identified and the descending colostomy is released with release of the splenic flexure and the gastrocolic omentum to about the middle colic vessels.
Dr. department was instrumental in providing advice, releasing the splenic flexure and dissecting the stapled rectum behind the uterus. Then I used a 28 mm sizer through the anus and I am able to incise the posterior uterine peritoneum so that I can feel the circumferential ring. We amputate the devascularize distal colon and with a noncrushing bowel clamp, introduced a 28 mm anvil and oversew with a pursestring 2-0 Prolene suture. This is connected following manufactures instruction, with the anti-mesentery facing upward, and a circumferential anastomosis completed. We tested with air in Betadine and water, and no visible leak. The distal colon and the proximal rectum donuts are intact and submitted separately. With exchange of gloves and instruments and all laparotomy pads accounted for, we divide the distalmost small bowel, about 15 cm segment, amputated between blue load staplers and seromuscular silk approximate the anti-mesentery, we open the enterotomy and create a stapled anastomosis with 55 mm blue load stapler. The enterotomy is closed in line with the original staple line, using a single application of the blue load TA 60 stapler. The mesentery is approximated with running lock 2-0 silk suture. All gloves and instruments are exchanged again.
We run the small bowel from ligament of Treitz to this site and then to the cecum, the appendix is surgically absent. Any serosal tears are closed transversely with simple interrupted or horizontal mattress 2-0 silk sutures. We inspect for active bleeding none found, oozing in the left lateral retroperitoneum is controlled dry laparotomy pad, point cautery, and then Fibrillar. Proximal to the stapled anastomosis in the right lower quadrant, I bring out the terminal ileum through a separate created stoma tunnel through the posterior and anterior rectus sheath, posteriorly open transversely and anteriorly opened longitudinally. A bleeding point was controlled with silk suture. The nondistended small bowel was brought through and a mesenteric window created and this is held eviscerated with a stoma post.
We had excise around the skin around the left colostomy, through the tunnel, separating it and bring it into the abdomen as part of the initial dissection. I now close the left lower quadrant posterior sheath transversely with running 0 Maxon suture. The anterior fascia is freshened from the muscle edge and that is closed longitudinally with simple interrupted Maxon suture. The stoma tunnel is cleaned and then closed transversely with vertical mattress 3-0 nylon suture and packed with half-inch iodoform gauze.
With all punches accounted for, the abdomen sought for additional retained foreign body such as laparotomy pad or instrument and none found, we closed the midline incision with #1 Maxon anchored above and below and tied centrally. The soft tissue was irrigated with saline and skin closed with staples.
I placed a stoma appliance around the ileostomy, and lays over the incision. I then make a transverse incision and mature with 3-0 Vicryl suture taking cuticle of skin, sidewall of intestine to the cut edge and evert both the afferent and efferent limb. With glove finger I show no marked narrowing of either limb and the external appliance is applied.