Sample Report: Hemicolectomy & Transverse Colorectal Anastomosis
PREOPERATIVE DIAGNOSIS: Refractory inflammatory bowel disease.
POSTOPERATIVE DIAGNOSIS: Refractory inflammatory bowel disease
PROCEDURE PERFORMED: Left hemicolectomy with transverse colorectal anastomosis.
FINDINGS: A few small plaques on the transverse colon (one excised for biopsy).
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was introduced. Her abdomen was prepped and draped in the usual sterile fashion with the patient in the modified lithotomy position. The previous midline scar was excised. The midline vertical scar was excised using a 10-blade scalpel. The subcutaneous tissues were divided with electrocautery. The fascia was also opened with electrocautery. The peritoneum was carefully grasped and entered. The incision was opened up along its length that extended from about 3 cm supraumbilical down to a few centimeters from the pubis. Gross peritoneal exploration was done. In the cul-de-sac, there was some fluid, which was submitted for cytology. There were a few plaques on the transverse colon. The liver was normal. I could not really evaluate the previous Nissen fundoplication from the lower abdominal incision. The colon looked normal. There was surgical absence of appendix.
The left colon was then dissected from the retroperitoneum. There was a fair amount of scar tissue, and this dissection took some time. The ureter was identified and was kept well out of the field of dissection. The greater omentum was dissected off the transverse colon to mobilize the splenic flexure. Resection was done by dividing the colon at the distal aspect of the transverse colon. I could see that there was essentially a branching blood vessel, probably the original middle colic artery, right at the area of the bowel I divided. I did take the left branch of the middle colic vessel and resect the mesentery. Vessels were ligated with clamps. This was done to where the rectum had been mobilized. The previous anastomosis was intact and widely patent.
A TA-55 stapler was applied across the rectum, about 3 cm below the previous anastomosis. Once the mesentery was divided, the TA stapler was fired. Attempts were made to save the superior hemorrhoidal vessels. The specimen was submitted to pathology. The transverse colon was then prepared for anastomosis. The staple line was excised, and a sizer was used to confirm that a 31-mm sizer fit easily within the lumen, secured with a pursestring suture. The remaining stapler was then passed up through the anus in the usual fashion and the spike advanced to the TA-55 staple line. This was fired, creating an anastomosis in the usual fashion. This was reinforced in a few areas using 3-0 silk popoffs. The TA-55 staple line outside of the anastomosis was also reinforced using interrupted 3-0 Lembert sutures. The anastomosis was then tested by placing it underwater and insufflating through the anus. This confirmed that the anastomosis was patent, and there was no evidence of bubbles or a leak. The water was evacuated. The mesenteric defect was then closed to prevent internal hernias. The small bowel was run from the ligament of Treitz to the cecum, and there were no abnormalities noted.
Attention was then turned towards closure. The fascia was reapproximated using a running 0 Vicryl suture. The skin edges were then approximated using skin clips. A sterile dressing was applied. The patient was extubated and an epidural catheter was placed. The patient was taken to the recovery room in stable condition.