DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
History of pelvic abscess following a Delorme procedure, status post fecal diversion with a loop ileostomy laparoscopically.
POSTOPERATIVE DIAGNOSES:
1. History of pelvic abscess following a Delorme procedure, status post fecal diversion with a loop ileostomy laparoscopically.
2. Anastomotic stricture.
PROCEDURES PERFORMED:
1. Closure of loop ileostomy.
2. Rigid proctoscopy with dilation of anastomotic stricture.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
POSTPROCEDURE CONDITION: Good.
SPECIMENS: None.
INDICATIONS FOR OPERATION: This patient has had rectal prolapse with adenomatous change. We performed a Delorme, and the patient developed a pelvic abscess with a fistulous communication to the anastomosis. The pelvic abscess was drained and then she had to be diverted. The patient now is over 3 months out and presents for elective closure. Preoperative CT scan with rectal contrast did not demonstrate any residual pelvic abscess or any fistulous communication. We discussed the risks of the procedure, which included anastomotic complications, wound complications, recurrent abscess formation, as well as alternatives. The patient noted understanding and elected to proceed.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed supine on the operating room table. The patient previously received preoperative antibiotics as well as heparin. After induction of general endotracheal anesthesia, the patient was frog-legged, and a gentle digital rectal exam was performed. The patient had a stricture at the previous anastomotic site, which was gently dilated with a fifth digit and then to the proximal interphalangeal joint of the first digit.
A rigid proctoscopic examination was then performed, and we were able to get past the anastomotic area. There was no mucosal abnormality, and the anastomosis was noted to be intact. Therefore, the patient was placed back on the operating room table in the supine position.
The patient’s abdomen was prepped and draped in a sterile fashion, and then using the cautery, a circumferential incision was made around the mucocutaneous junction of her ileostomy. Dissection was carried down to the fascia circumferentially, and then the small bowel was detached from the fascia. There were absolutely no adhesions below the fascia, and we were able to easily deliver the two limbs of the loop ileostomy. The adhesions between the two limbs were then taken down sharply, and the edges were trimmed.
At this point, we chose to place the GIA-45 blue load down both limbs and anastomosis created using a functional end-to-end, side-to-side anastomotic technique, and the enterotomies were closed with a TLH-60 stapler. The anastomosis was then delivered back into the abdomen, and we irrigated the abdomen and aspirated it. Then, we closed the fascia with interrupted 0 Vicryl figure-of-eight sutures after clearing it of its fatty attachments using the cautery.
The whole wound was then thoroughly irrigated with Kantrex saline, and then we undermined the skin and trimmed it so that it would come together without dog ears and then loosely closed it with interrupted 3-0 Vicryls. Kantrex-soaked Nu-Gauze was then placed in the ileostomy closure site loosely. This was to serve as wicks. Dry dressing was applied. The patient was then taken to the recovery room, where she was noted to be good condition without apparent immediate complications.
