PROCEDURE: Exploratory laparotomy. Rectosigmoid resection. Mobilization of the right colon, hepatic and splenic flexures. Debridement of right retroperitoneal space.

A standard midline incision was performed. Prior to entering the peritoneal cavity, there was a purulent infection noted coming from the right lower quadrant and right mid abdominal retroperitoneal space. Upon entering the abdominal cavity, there was murky peritoneal fluid but no obvious succus entericus identified. The omentum was matted and fixed to a pelvic inflammatory/neoplastic mass. The omentum was mobilized by dividing it between Kelly clamps and tying off with 0 silk suture. Loops of the terminal ileum or fixed to the mass as well but not incorporated by it. The inflammatory adhesions were taken down freeing the small intestine from the pelvic mass.
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Once it was decided that the the pelvic mass was the probable source of perforation and sepsis and resection was eminent, the right hemiabdomen was explored by mobilizing the right colon. There was evidence of a previous appendectomy. The right ureter was identified. There was a foul-smelling diffuse infectious process involving the soft tissues of the right retroperitoneum, incorporating the renal space. The hepatic flexure was mobilized and the duodenum exposed. There is no bile staining in the sub-hepatic space and the duodenum appeared intact and without inflammation as did the stomach and gallbladder. The NG tube was palpated. The liver appeared normal. There is a small hemangioma in the left hepatic lobe. The necrotic tissue of the right retroperitoneal space was excised.
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The small bowel was run from the ligament of Treitz to the ileocecal valve and there is no evidence of perforation or malignancy. The transverse colon was palpated and normal. The left colon–sigmoid colon junction was then divided with a TA stapler. Mesentery was scored medially and the left colon/sigmoid avascular line was incised to fully mobilize the left colon and sigmoid. The sigmoid colon mesentery was divided between Kelly clamps and tied off with 0 silk suture. Left ureter was identified and protected. The inflammatory–possibly neoplastic mass was then mobilized from the pelvic sidewall. Upon dividing the dense tissue surrounding the mass, a small colotomy was created. The posterior rectal space was entered allowing for isolation of the lateral stalks that were divided under direct vision using sharp dissection and cautery. The inflamed anterior space was entered as well allowing for the contour stapler to encompass the superior rectum for excision of the rectosigmoid. 0 Prolene sutures were placed on the lateral aspect of the superior rectum for future identification. The left colon was viable and mobilized to the splenic flexure.
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Anesthesia department reported difficulty maintaining the patient’s blood pressure despite maximum fluids and pressor agents. Therefore the decision was made to irrigate the abdomen with several liters of warm saline and to place an AB Thera device for closure and to take the patient back for a second look in 24-48 hours. There was diffuse oozing from the right retroperitoneal space. Upon mobilizing the liver by dividing the ligamentum teres, there was a small tear made in the left lobe that was cauterized and a small piece of Surgicel placed for hemostasis. Otherwise there is no significant bleeding. Sponge needle count was correct. The abdomen Ab Thera was placed to vacuum suction with a good seal. The patient was then taken to the intensive care unit intubated and stable but in critical condition.
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