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Preoperative Diagnoses: Extensive diverticulitis of sigmoid colon...

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Preoperative Diagnoses: Extensive diverticulitis of sigmoid colon...

Preoperative Diagnoses: Extensive diverticulitis of sigmoid colon with perforation; obstruction of right colon and proximal transverse colon due to Crohn's disease. Protein Calorie Malnutrition, BMI 27.2

Postoperative Diagnosis:  Same

Procedures: Exploratory laparotomy; sigmoid colectomy; extended right hemicolectomy; permanent colostomy               

Procedure Description:  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 received 3 g of IV Unasyn.  The patient was placed under general endotracheal anesthesia.  PAS stockings were applied to both 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.  With exploration of the abdomen, extensive diverticular disease of the distal sigmoid colon was noted.

First order of business was to mobilize the sigmoid colon for a sigmoid colectomy.  The left ureter was identified and was far from the area of the sigmoid colon.  The sigmoid colon was mobilized laterally to include the area of the diverticulitis.  The sigmoid colon was mobilized down to the peritoneal reflection.  The medial aspect of the sigmoid colon was also mobilized.  The colon was then completely mobilized.  A point of transection was chosen at the proximal 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 was a blue load.  Both the right and left ureters were identified prior to any transection of the sigmoid colon.  A 3-0 Prolene suture was then tagged to either edge of the rectal staple line.

The right colon was then inspected.  Multiple perforations with sites of deserosalization with exposed mucosa were identified in the right 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.  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 bowels 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 enterostomies 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 3-0 Vicryl suture in a running fashion.

Attention then turned toward 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 two 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 32.

The midline fascial incision was then closed with a running #1 looped PDS 32.  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 sown 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.

 

 

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Answer & Explanation

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Answered by jkcn0417 on coursehero.com

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Step-by-step explanation

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