Post-op Diagnosis
* Enterocutaneous fistula [K63.2], anastamotic leak
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Procedure(s) (LRB):
EXPLORATORY LAPAROTOMY WITH ILEOCOLECTOMY (N/A) Takedown of splenic flexure.

We made a upper midline incision excising the prior extraction incision through which the stool from the fistula had drained. We entered the abdomen superiorly in a free space and divided the fascia just to the left of the fistula and eventually separated the fistula from the abdominal wall with minimal spill of stool. There was old stool staining the fascia along the edges of our fascial incision.
We sharply and bluntly took down small bowel adhesions around the old anastamosis until we could identify the loop of small bowel entering the anastamosis and the distal transverse colon exiting it. We divided some omentum stuck over the superior aspect of the anastamosis with the IMPACT ligasure. We divided the mesentery to the small bowel and colon side of the anastamosis staying high in the mesentery with the ligasure. We divided the small bowel through viable soft small bowel about 5-10cm proximal to the anastamosis with a GIA 75 blue 3.5 mm stapler. We divided the transverse colon also about 5-10 cm distal to the anastamosis through viable soft colon also with a GIA 75 blue 3.5 mm stapler. Both staple lines were turned in with 3-0 silk lembert sutures. I should note that there were a few serosal tears incidental to the procedure in the small bowel that were closed with interrupted 3-0 silk suture.
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We took down the splenic flexure to insure there would be no tension on the new ileocolic anastamosis, taking care to avoid injury to the spleen. We considered making an ileostomy as the bowel was a little thickened and inflamed still but it was relatively normal and sutures that we tied down held well. The blood supply was clearly excellent, the patient was stable, and there were no fibrinous exudates and we felt the an anastamosis should have an excellent chance of healing and would clearly be better for her than an ileostomy.
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A functional end to end anastamosis was then constructed handsewn side to side. I chose a handsewn anastamosis due to the slight inflammation and thickening of the bowel. It was two layer handsewn with interrupted 3-0 silk suture for the outer layer and running 3-0 vicryl suture for the inner layer. Hemostasis appeared excellent. All the bowel appeared pink and healthy. Care was taken to avoid twists in the mesentery. We then placed additional sutures on both sides of the anastamosis sewing the bowel together to try to make sure that she would not get a leak at the corners of the longitudinal suture line. Her small bowel mesentery is very thick and fatty and I expect when she stands up it is quite heavy. Stool spill was minimal intraop. She had some residual omentum in the left upper quadrant. The ileocolic anastamosis was to the distal transverse colon. We sewed the omentum over the anastamosis with two 3-0 silk sutures.
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We then excised the abscess cavity some of which was impregnanted with old stool from the fat and fascia of the midline wound. We did excise some midline fascia but as little as possible. The abdomen was thoroughly irrigated with multiple liters of saline.