Procedure(s):
Sigmoid Colectomy, omentectomy, release splenic flexure Procedure Note

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Pre-op Diagnosis:
SIGMOID VOLVULUS
ISCHEMIC COLON K55.9

Post-op Diagnosis: SAME
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CPT Code: Procedures:
* Sigmoid Colectomy, omentectomy, release splenic flexure.
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Indications: Sepsis, black mucosa of sigmoid colon on detorsing sigmoidoscopy.
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Description of Procedure: While already in OR 5 under GA, we complete time out and shave the abdomen. The anesthesia service has placed support lines. The abdomen is clipped (shaved) and prepped with chlorhexidine and draped after 3 minutes. A midline incision from above the umbilicus to suprapubis is created and later extended cephalad to visualize and release the splenic flexure. The dark purple-black thick and distended sigmoid colon is released from overlying congested omentum by dividing omentum with Ensure and the sigmoid had torsed again that proximal sigmoid was in the left pelvis. Once rotated and delivered, the sharp demarcation of descending colon with sigmoid is recognized. The line of Toldt is barely visible with markedly thickened peritoneum and markedly distended colon to about 12 cm. The peritoneum is scored and released that the distal descending colon can be encircled and I divide with 100 mm green load GIA. I release mesentery with scoring with cautery and division with Enseal, separating and thinning the mesentery to avoid injury to ureter. I elevate the mobilized redundant colon to skin level and continue to divide mesentery with Enseal. The proximal rectum is thick but the demarcation line evident. The peritoneum is thick and by elevation the cul de sac is seen but I don’t need to divide mesorectum, we stay more proximal at the promontory. I encircle here and elevate and divide with green load GIA. The remainder of thick mesentery on each side scored and divided with Enseal til removed. The left ureter is identified, the right peritoneum had not been opened and dissection medial to natural course of right ureter. Now the infarcted and congested omentum is removed along the transverse colon with Enseal. One bleeding point of divided descending mesentery is found and responsible for most of today’s operative blood loss, about 75 mL and the pedicle is tied with 2-0 silk. The descending stump is released more proximally but will not reach a Lower Quadrant stomal tunnel. I extend the incision and release the gastrocolic omentum on the left, the splenocolic ligament with no injury to visualized lower pole of spleen. Mesentery is released off kidney until the mobilized colon can reach beyond a left upper quadrant tunnel. A plug of skin is excised, the fascia and muscle split longitudinally and the stapled stump can be drawn through the tunnel to the outside skin surface about 1 1/2 inches.
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All laparotomy pads are removed, the abdomen irrigated with clear return; no evident bleeding. Small bowel lays normally, the appendix and cecum in the right. The right and transverse colon was so distended that I felt compelled to mature, hence abdominal closure and stoma maturation. I close the loose abdomen with running #1 Maxon and skin loose closed at 3 cm intervals with staples. A Prevena vac system is applied. The stoma appliance lays partly over the Prevena. The staple line is cut and stoma matured with cut edge, side wall and cuticle of skin approximation with 3-0 vicryl. The mucosa is viable but beginning purple discolored as much from pressors but viable. I use a
Gloved digit to verify the tunnel not too narrowed and it isn’t. An appliance is applied.