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- PREOPERATIVE DIAGNOSIS: Perforated descending colon diverticulitis.
- POSTOPERATIVE DIAGNOSIS: Same.
- Laparoscopic extended left hemicolectorny with colorectal anastornosis.
- LaparoScopic Splenic flexure mobilization.
- ANESTHESIA: General
- FINDINGS: Inflammation in the descending colon with perforation.
INDICATIONS FOR PROCEDURE:
The patient is a 52-year-old female who presented with worsening pain for several days. She was found to have significant inflammation of the descending colon with extraluminal air and early peritoneal signs on exam. Risks and benefits were discussed with the patient who understood and agreed with the treatment plan.
DESCRIPTION OF PROCEDURE:
After obtaining proper informed consent, the patient was taken to the operative suite where she was prepped, draped and positioned in the usual fashion. Preoperative antibiotics were given, SCDs were placed prior to induction of general anesthesia. A timeout was performed and was correct.
A 2 cm infraumbilical incision was made and carried through skin and subcutaneous tissue. The fascia was identified, was incised and a 12mm Hasson trocar was inserted. The abdomen was insufflated with carbon dioxide gas. Under direct vision a 12mm trocar was placed in her lower midline in the previous C section scar, and-a 5 mm was placed in the right lower quadrant. The colon was identified. There was some inflammation on the descending colon. Mobilization occurred laterally to medially, starting at the sigmoid colon. The retroperitoneal attachments were taken down. The left ureter was identified over its full course. Dissection occurred proximally up through the splenic flexure. The splenic flexure was taken down from the gastrocolic attachments and the oriental attachments, getting adequate mobilization to anastomose the distal transverse colon down to the rectum.
Dissection occurred distally to the reclosigmoid junction. The mesentery was transected with the Harmonic scalpel from the sigmoid artery, and the left colic artery were taken. This was carried down to the rectosigmoid junction. Using an Endo-GIA 45mm blue load staple, the rectosigmoid junction was transected. Dissection of the mesenteric occurred proximally through the splenic flexure. There was adequate mobilization, and it reached easily down into the pelvis.
At this point in lime, a 4 to 5 inch Pfannenstiel incision was made in her previous C-section scar. This was carried down through skin and subcutaneous tissue. The fascia was incised. The muscle was split in the midline. An Alexis wound protector was inserted and the Colon was externalized. There was an area of perforation with a small piece of stool that was exiting the colon. Proximal to this was normal appearing transverse colon. A 2-0 Prolene pursestring was applied. The colon was transected and the specimen was sent to pathology. A 29 EEA anvil stapler was put in the open end of the colon, and the pursestring was tied down and cut. This was then internalized again. The fascia was closed with a #1 PDS. The abdomen was reinsufflated. A 5 mm trocar was placed under direct vision in the Iower midline. Again, it was-checked to make sure there was adequate length to make a tension-free ariastomotis, and there was.
The EEA stapler was brought through the anus and brought up anterior to the staple line. The anvil was deployed. The 2 ends were mated and closed. The stapler was fired and removed. Two complete donuts were seen. A proctoscope was then inserted and a leak test was performed with air 3 different times with no air leak that was seen. The pelvis and the left hemi-abdomen were irrigated with a liter of normal saline. There was no other sign for any pathology. A 10 flat JP drain was placed in the pelvis and brought out through the right lower quadrant incision. The abdomen was then desufflated, trocars were removed under direct vision. The fascia of the umbilical incision was closed with an 0 Vicryl suture. Skin was closed with 4-0 Monocryl. Dermabond was applied. The patient tolerated the procedure well. She was extubated and taken to recovery in stable condition.
- 44207 – Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis)
- 44213 – Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure)
- K57.20 – Diverticulitis of large intestine with perforation and abscess without bleeding