GI & GU
Left Partial Nephrectomy
PREOPERATIVE DIAGNOSIS: Mucocutaneous separation of end sigmoid colostomy.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Exploratory laparotomy with revision of colostomy.
ANESTHESIA EMPLOYED: General by endotracheal tube.
ATTENDING SURGEON: R. P., MD.
ASSISTANT SURGEON: R. C., MD.
SUMMARY OF PROCEDURE PERFORMED: Mrs. L is a 75-year-old woman with a history of bullous emphysema who initially presented to an outlying hospital with coughing and shortness of breath. While at the outlying hospital she developed a spontaneous pneumothorax, which required placement of chest tube. She was transferred to the B Hospital for management of persistent air leak and subcutaneous emphysema. Upon admission to the B Hospital she was found to have abdominal pain and pneumoperitoneum. She was taken to the Operating Room three days ago for exploratory laparotomy, which identified perforated sigmoid diverticulitis. She underwent a sigmoid colectomy with end-colostomy and hearts and pouch. She has mucocutaneous separation of her end-sigmoid colostomy and for that reason requires revision of her colostomy. I discussed this situation with her husband, and discussed the potential complications of bleeding, infection, injury to surrounding structures, and prolonged intubation. He understood and wished to proceed with exploratory laparotomy and revision of the colonoscopy.
Mrs. L was brought to the Operating Room. She had already been intubated and was on propofol and so anesthesia was completely administered in the Operating Room. Her abdomen was prepped and draped in the standard surgical fashion. We opened up her prior midline incision. We entered the peritoneal cavity. There were few adhesions. We were easy able to eviscerate the small bowel. There was a good amount of blood clot found in the pelvis, and this was all irrigated and removed. We evaluated the Hartman stump. This appeared to be intact. However, we oversewed the Hartman stump with 2-0 Prolene suture in running continuous fashion. Next we turned our attention to the left upper quadrant and to the ostomy. We cut all sutures, which were still intact between the end-colostomy and the skin. Next we pulled the colostomy back into the peritoneal cavity. The colostomy was found to be viable and it had just suffered some separation inferiorly. At this point I proceeded to close the old ostomy incision. I closed posterior sheath with interrupted figure-of-eight sutures of 0 Vicryl. I closed the anterior sheath using interrupted figure-of-eight sutures of number 1 nylon. Next I irrigated this wound copiously in order to remove any blood clot or contamination in the area. Now we turned out attention to mobilizing the colon. We completely mobilized the splenic flexor of the colon. This was done so by incising the peritoneal flexion with electrocautery. Once the splenic flexor was completely mobilized, we were able to lift the colon near the anterior abdominal wall. I did, however, have to cut back at the root of the mesentery in order to achieve more complete mobilization. Now we chose a site for the colostomy, which was in the left upper quadrant, somewhat superior to the old colostomy site. We incised the skin with a electrocautery. We then dissected down through subcutaneous fat using electrocautery. Upon reaching the abdominal fascia, we incised the anterior sheath in a cruciate manner. We also incised the posterior sheath in a cruciate manner. We were able to fit two fingers through our fascial incision without any difficulty. Now we placed a Babcock clamp through the fascial incision and grasped the end of the colon. We retracted the colon up out of our new colostomy incision. This was found to lie quiet nicely on the abdominal cavity. At this point we further irrigated the peritoneal cavity. Next, we proceeded to close the abdominal fascia. We did so by running a suture of number 2 nylon. In addition to this we placed interrupted fascial sutures in figure-of-eight fashion of number 1 Maxon. Finally, we placed four retention sutures of number 2 nylon. In this fashion the abdominal cavity was closed. The skin was left opened. Now we turned to maturing our colostomy. We cut off the end of the colostomy with the electrocautery. The colostomy was found to be nicely healthy, viable, and bleeding. We sutured the colostomy to the dermis using interrupted suture of number 3-0 Vicryl. Again, the colostomy was found to be healthy and not under any tension at this point. We dressed the colostomy with a colostomy with a colostomy appliance. We dressed the midline abdominal wound with moistened fluff gauze, followed by AVD pads. Mrs. L. tolerated the procedure. She was transferred to the Surgical Care Unit, intubated and in serious, but stable condition.