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PREOPERATIVE DIAGNOSIS: Descending colon cancer.
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POSTOPERATIVE DIAGNOSIS: Same.
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PROCEDURE: Laparoscopic deepening hemicolectomy.
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ANESTHESIA: General.
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ESTIMATED BLOOD LOSS: 30 mL.
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FINDINGS:
1. A firm mass at the proximal descending colon with tattoo just distal to this.
2. No evidence of gross metastatic disease.
3. Good margins on gross pathology.
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INDICATIONS FOR PROCEDURE: The patient is a 69-year-old gentleman who was found to be anemic and underwent colonoscopy. This was then completed, a large mass was identified at the proximal descending colon and was unable to be traversed. This was tattooed distally. A CT scan did not reveal any evidence of obvious metastatic disease and also revealed a near obstruction to the colonoscopy. Given these findings, surgical intervention was indicated. The risks, benefits and alternatives of procedure were discussed with the patient and he wished to proceed.
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He underwent ERAS protocol.
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DESCRIPTION OF THE PROCEDURE: The patient was taken to the operating room theater. He was placed in supine position. General anesthesia was induced. Preoperative antibiotics were administered. The patient’s abdomen was prepped and draped in normal sterile fashion after he was placed in modified lithotomy position. All trocar sites were anesthetized using local anesthetic. A right lateral abdominal incision was then made. Under countertraction an optical viewing trocar was placed. Pneumoperitoneum was established to 14 mmHg. The abdomen was inspected and found to be no evidence of trocar related injury. Two 5 mm ports were placed in the epigastrium. A 5 port was placed in the left lower quadrant and 12 port placed in the suprapubic location.
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The abdomen was inspected. There was found to be no evidence of metastatic disease and no disease to the peritoneum. The descending colon was then evaluated. He has a mass that was able to be palpated with laparoscopic graspers and tattooing is noted just distal to this. The mid portion of the transverse colon was then identified and the omentum was taken down off the nearly the entirety of the transverse colon so that this could be mobilized. This was then continued laterally to the splenic flexure. The descending colon and sigmoid colon were then retracted medially and mobilized as well. The splenic flexure was then completely mobilized. At this point, we then selected the transection point of the descending colon. I did elect to keep the sigmoid colon to allow for anastomosis as it was felt with his morbid obesity that the transverse colon would not reach into the pelvis. The IMA was preserved. A defect was then made distal to the tattooed site. This was then transected with a blue load GIA stapler. Next, the mesentery was taken down to the root of the mesentery. This was then continued to the mid portion of the transverse colon. The vascular pedicle was taken with a vascular load stapler. This was then carried out to the mid transverse colon and this was stapled with a blue load as well. The distal aspect was then grasped. The lower midline wound was then extended. A wound protector was placed. The specimen was then removed from this. He does have a large palpable mass at the proximal descending colon site. This was then passed off to pathology. There was found to be excellent margins. Pneumoperitoneum was then reinsufflated. The abdomen was inspected. There was found to be excellent hemostasis. The proximal transverse colon was then able to be brought down to reach the sigmoid colon. These were brought together in a side-to-side fashion. Stay stitch of 2-0 silk was placed to the ____ x2. Colotomies were then made on each limb and the anastomosis was then created in a side-to-side fashion using 2 successive firings of the 60 blue load Endo-GIA stapler. The common colotomy was then closed in 2 running layers with 2-0 silk. This resulted in excellent closure. The mesenteric defect is a broad-based and thus it was not closed. There was found to be excellent hemostasis. Pneumoperitoneum was then released and trocars removed. The lower midline fascia was then closed with a #1 PDS Plus suture running proximally and distally to tie in the middle. Additional local anesthetic was infiltrated to this site. The dermis was then closed with Vicryl and all skin sites were then closed with 4-0 Monocryl in a subcuticular fashion. Steri-Strips and sterile dressings were applied.
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The patient tolerated the procedure well. There were no complications. All counts were correct as reported at the end the case.
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D:12/15/2017 15:27 T:12/15/2017 21:42:23 hn Job#: 040699
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cc: James V Rider
cc: Balaji S Datti
cc: Andrew D Meyer
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Admission (Discharged) on 12/15/2017
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Routing History
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Detailed Report
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