DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Perforated viscus.
POSTOPERATIVE DIAGNOSES:
1. Perforated descending colon diverticulitis.
2. Purulent peritonitis.
3. Obesity.
PROCEDURES PERFORMED:
1. Left colon resection with colorectal anastomosis.
2. Complete mobilization of the splenic flexure.
3. On-table colonic lavage.
4. Placement of On-Q pain control device.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 100 mL.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old man who presented to the emergency room with complaints of acute abdominal pain. CT scan of the abdomen and pelvis revealed evidence of a perforated viscus and suggestion of perforated diverticulitis. The patient was marked for a stoma preoperatively and planned to have a colon resection with construction of end colostomy.
DESCRIPTION OF OPERATION: The patient was brought to the operating room, placed on the operating room table in the supine position. After adequate induction of general anesthesia with endotracheal intubation, a Foley catheter was placed without difficulty. The abdomen was then shaved, prepped and draped in the usual sterile fashion. A midline incision was made and carried out sharply down to the fascia, which was opened, taking care to avoid injury to underlying organs. Upon entering the abdomen, there was a small release of free air and cloudy fluid was seen. There was no evidence of gross fecal contamination.
Exploration revealed the small bowel to be normal. There appeared to be a walled inflammatory mass of the mid descending colon densely adherent to the left paracolic gutter that had broken free. There was no gross spillage of stool, but there was a dense inflammatory reaction around this part of the colon. In addition, the sigmoid colon was very hypertrophic. The patient’s proximal and distal colon were full of solid stool.
Because of the patient’s otherwise good health and hemodynamic stability, we decided to perform left colon resection with concurrent on-table colonic lavage and primary anastomosis. This required complete mobilization of both the hepatic and splenic flexure. Once this was done, an appendectomy was performed and a 24-French Foley was placed into the appendiceal orifice. This was secured with a pursestring suture. Sterile corrugated tubing was then placed into the proximal descending colon, just above the area of perforation. This too was secured with a pursestring suture. Three liters of warm saline were then used to lavage the colon until clear. The Foley catheter was removed from the appendiceal orifice and this was stapled closed. The staple line was oversewn with interrupted 3-0 Vicryl sutures.
Left colon resection was next performed. This was done by transecting the distal transverse colon between an automatic pursestring device and a Kocher clamp. The anvil of the 29 mm circular stapling device was placed in the proximal colon and the pursestring was secured. The sigmoid branches of the descending colon were then taken down, carefully preserving the inferior mesenteric artery. The rectosigmoid junction, where the taenia splayed out on the anterior wall of the rectum, was then divided with the TLH 60 stapling device. A tension-free, well-vascularized, end-to-end anastomosis was performed without difficulty. This anastomosis was reinforced with interrupted 3-0 Vicryl sutures. The pelvis was filled with saline and air insufflation was performed. There was no evidence of air leak.
Copious irrigation of the intra-abdominal cavity was performed with Kantrex in saline. The remainder of the bowel appeared completely healthy. Therefore, the small bowel was returned to the intra-abdominal cavity in gentle S-shaped curves and covered with omentum and Seprafilm. The sponge and needle counts were reported correct by the nurse in charge. The posterior sheath was closed with chromic, and the fascia of the abdominal wall was closed with two separate looped 0 Maxon sutures. Two separate long On-Q catheter devices were placed in the subcutaneous tissues lateral to the vertical incision. The incision was then closed with 3-0 Vicryl sutures and staples. The patient tolerated the procedure well without complications and was then awakened, extubated and returned to the PACU in stable condition.
