DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Lesion of the right colon.
POSTOPERATIVE DIAGNOSIS: Lesion of the hepatic flexure.
OPERATION: Right hemicolectomy and ventral abdominal herniorrhaphy.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: With the patient adequately anesthetized under general anesthesia and after having already undergone mediastinoscopy, the abdomen was prepped and draped in the usual fashion.
The previous periumbilical midline scar was excised sharply. Dissection was performed down to the midline fascia, which was carefully incised and the abdomen was entered. The remainder of the midline fascia was then incised using electrocautery. The fascial edges were then elevated with Kocher clamps and dense omental adhesions to the midline and laterally on both sides were taken down sharply. This revealed a string-of-pearls type hernia in the right upper abdominal fascia. These hernia sacs were emptied of the omentum, thus freeing up the omentum in order to be able to retract it aside.
Once this portion of the procedure was done, the right colon was grasped and swept to the midline by incising along the left lateral gutter. This was done using electrocautery. This dissection continued around the hepatic flexure to free up the colon to the level of the mid transverse colon. The terminal ileum and right colon were then deprived of its blood supply by clamping and ligating the mesenteric vessels with a series of 2-0 or 0 silk ligatures. When the terminal ileum and colon across the level of the hepatic flexure were completely deprived of blood supply, a GIA stapler was used to transect the terminal ileum and the colon. The specimen was removed from the wound. This was sent to pathology for gross pathologic review.
The colon and ileum were then sutured side by side using a series of 3-0 silk sutures. The corners of the staple lines were removed and the GIA was inserted and fired. The resultant defect was then closed with TA-60 stapling device. The anastomosis was patent and well perfused. The mesenteric defect was then closed with running 2-0 Vicryl suture. By that time, the gross inspection of the colon specimen had been performed and the pathologist called and stated that the lesion itself was very close to the distal margin. The anastomosis was therefore then excised by clamping and ligating the distal ileum across the mesenteric defect to the mid transverse colon, thus providing 4 cm to 5 cm colonic margin on lesion. The GIA was inserted in the ileum and fired and also across the transverse colon and fired. The specimen was removed from the wound.
Once again, a functional end-to-end anastomosis was performed by suturing the colon and the ileum side by side. The corners of the staple lines were excised. The GIA stapler was fired and the resultant defect was closed with TA-60 stapler. When the anastomosis was proved patent, the defect was again closed with running 2-0 Vicryl suture. The abdomen was copiously irrigated with normal saline solution. By this time, the pathology on the second gross specimen revealed a good margin on the lesion.
The abdominal fascia was then closed, including the two hernias to the right of the original midline wound, with running #1 looped PDS suture starting at both apices and tying in the middle. Subcutaneous tissue was closed with 3-0 Vicryl suture and the skin was closed with a running 4-0 Vicryl subcuticular stitch. Steri-Strips were applied and the wound was dressed. The patient returned to the recovery room awake, extubated, in stable condition. All counts were correct at the end of the case x2. There were no complications. Blood loss was 250 mL.
