1. Sigmoid stricture.
2. Colonic perforation following colonoscopy.
1. Sigmoid stricture.
2. Perforations of the right colon and proximal transverse colon.
1. Exploratory laparotomy.
2. Sigmoid colectomy.
3. Extending the right hemicolectomy with ileocolic anastomosis.
4. End-descending colostomy.
FINDINGS: The patient had a tight sigmoid stricture in the pelvis with the sigmoid colon adherent to the left pelvic sidewall which appears to be related to diverticular disease. She had multiple perforations, approximately 6 areas of deserosalization with areas of exposed mucosa of the right colon and proximal transverse colon. Findings were most consistent with colonic distention at the time of her colonoscopy. The remainder of her transverse colon and descending colon were normal in appearance.
ESTIMATED BLOOD LOSS: Estimated blood loss is 150 mL.
SPECIMEN: Right colon and sigmoid colon.
FLUIDS: IV fluids were 2400 mL of lactated Ringer?s. Urine output was 300 mL.
COUNTS: Sponge, needle, and instrument counts were correct at the end of the case.
DESCRIPTION OF PROCEDURE: After consent was obtained for the procedure, risks and benefits were described at length. The patient was taken to the operating room and placed supine on the operating room table. Preoperatively, the patient had received 3 g of IV Unasyn. The patient was placed under general endotracheal anesthetic. PAS stockings were applied to both lower extremities. The patient?s abdomen was then prepped and draped in the standard surgical fashion.
A midline laparotomy incision was made from just around the umbilicus to the pubic symphysis. The midline of the fascia was divided, and the abdomen was entered. Approximately 200 mL of blood-tinged serous fluid was noted in the pelvis. With exploration of the abdomen, a tight stricture was noted in the pelvis in the distal sigmoid colon as it was adherent to the left pelvic sidewall. With examination of the colon, the obvious areas of perforation were identified in the right colon starting just at the cecum and moving proximally towards the hepatic flexure.
First order of business was to mobilize the sigmoid colon for a sigmoid colectomy to remove this area of stricture. The sigmoid colon was taken down by referring to the white line of Toldt along the left pelvic sidewall and the paracolic gutter. The left ureter was identified and was far from the area of the sigmoid colon or from the stricture. The sigmoid colon was mobilized laterally to include the area of this tight stricture. It was quite densely adherent to the pelvic sidewall. The sigmoid colon was mobilized down to the peritoneal reflection. The medial aspect of the sigmoid colon was also mobilized. The colon was completely mobilized. A point of transection was chosen at the proximal sigmoid colon, and a GIA 45 stapler with a blue load was used to transect the sigmoid colon. The mesentery was then taken down across the sacrum. The vessels were tied with 2-0 silk sutures. The sigmoid colon was mobilized down to the proximal rectum. Once the proximal rectum was identified, the sigmoid colon was again transected this time using a contour Ethicon stapler with a blue load. The sigmoid colon was then passed off the field as specimen. Again, both right and left ureters were identified prior to any transection of the rectum. A 3-0 Prolene suture was then tagged to either edge of the rectal staple line for aided ability in identifying the rectal stump on a later operation.
The right colon was then inspected again, and again multiple sites of deserosalization with exposed mucosa were identified in the right colon as well as in the proximal transverse colon. The right colon was mobilized by taking down the white line of Toldt all the way up to and including the hepatic flexure. The omentum was taken off the transverse colon with electrocautery. Once the colon was completely mobilized and became a medial structure, the terminal ileum was transected this time also using a 45-mm GIA stapler with a blue load. A point of transection was chosen in the mid transverse colon just proximal to the middle colic artery where the last site of deserosalization was identified. There were areas of emphysematous changes within the omentum of the transverse mesocolon suggesting areas of extrapolated air. The mid transverse colon was divided with a GIA 45-mm stapler with a blue load. The mesentery to the right colon and transverse colon were then taken down with Pean clamps and tied with 2-0 silk sutures. The specimen was then passed off the field.
The abdomen was then irrigated. Hemostasis was assured. The ileocolic anastomosis was then created between the terminal ileum and the mid transverse colon. The bowel were positioned to lie along side each other, and a side-to-side functional end-to-end anastomosis was created using a 45-mm GIA stapler with a blue load. The enterotomies were then closed together with a running 3-0 PDS suture followed by interrupted 3-0 GI silks in a Lembert fashion. A stitch was placed at the crotch of each of the bowel connections. A finger was palpated at the anastomosis, and it was widely patent. Mesenteric defect was then closed using a 3-0 Vicryl suture in a running fashion.
Attention was then turned towards formation of the end-descending colostomy. The descending colon had already been mobilized enough to make it to the anterior abdominal wall without any difficulty. A point on the anterior abdominal wall on the left-hand side just below the umbilicus was chosen for the colostomy. A small 1.5- to 2-cm circular incision was made on the anterior abdominal wall midway through the rectus muscle. The anterior fascia was divided in a cruciate fashion. The rectus muscles were split, and 2 fingers were palpated through the defect into the abdominal cavity. The descending colon was then grasped with an Allis clamp and passed through the defect and exteriorized. There was no tension on the colon. On the undersurface of the peritoneum, the colon was tagged with 3-0 GI silk sutures x2.
The midline fascial incision was then closed with a running #1 looped PDS x2. The surgical incision was then irrigated with copious saline. The skin was then closed with surgical staples. The ostomy was then matured by removing the staple line and sewing the ostomy in place with 3-0 Vicryl sutures. The sutures were sewn in circumferentially. An ostomy appliance was applied.
Sterile dressings were applied, and the patient was awakened from general anesthesia and transported to the recovery room in stable condition.