PREOPERATIVE DIAGNOSIS: Inflammatory phlegmon in the right lower quadrant.
POSTOPERATIVE DIAGNOSIS: Inflammatory phlegmon in the right lower quadrant, likely secondary to perforated cecal diverticulitis.
OPERATION PERFORMED: Exploratory laparotomy through a right lower quadrant incision with a right colectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 500 mL.
COMPLICATIONS: None apparent.
DRAINS: Jackson-Pratt x2.
SPECIMENS: Right colectomy.
DESCRIPTION OF OPERATION: After informed consent was obtained from the patient and after the possible operative risks, complications, and alternatives were discussed, he was taken to the operating room and placed on the operating table in the supine position. Anesthesia was induced. The patient was intubated. The abdomen was shaved and prepped with Betadine and draped sterilely. A transverse incision was made in the right lower quadrant. The incision was deepened with electrocautery. The fascia was entered, the muscle fibers were split, the peritoneum was entered, and retractors were placed on the wound. The cecum was obviously severely inflamed with a large inflammatory phlegmon. It was impossible to mobilize without extending the incision and dividing the abdominal wall musculature. A self-retaining retractor was assembled and used to maintain retraction of the abdominal wall for better visualization. The inflammatory phlegmon was rather massive and involved the ileocolic mesentery and the right paracolic gutter extending into the pelvis. The appendix was located in this but was not clearly the source of this. There was a large abscess that was freely draining pus from posteriorly and this appeared to be adjacent to the cecum and not necessarily arising from the appendix itself.
The etiology was thought to be most likely cecal diverticulitis. Regardless, a wide resection with right colectomy was indicated. The terminal ileum was divided with a GIA stapler, including in the resection specimen a small portion of the terminal ileum at the ileocecal valve that was indurated and inflamed. The mesentery to the ileocecal area was divided with LigaSure with good hemostasis. The right colon was mobilized along the right paracolic gutter. There was some difficulty with the fixation due to the phlegmon and mobilizing the hepatic flexure. Ultimately, the transverse colon was divided in its proximal portion, and working backward using LigaSure, it could be divided from its omental attachments, gastrocolic attachments, and its mesentery. When the specimen was entirely free, it was forwarded to pathology. The transverse colon was seen to reach easily to the terminal ileum. Both segments of bowel were grossly normal at this area, healthy and viable. The mesenteric defect was approximated with PDS suture. The bowel ends were placed in approximation with PDS suture and a stapled side-to-side functional end-to-end anastomosis was accomplished with the GIA stapler. The defect created by the stapler and anastomosis was closed in two layers with 3-0 Vicryl and interrupted 3-0 PDS Lembert sutures.
The wound was irrigated and the irrigant suctioned out. Sponge, needle, and instrument counts were correct. Inspection for hemostasis showed that there was still a small amount of oozing along the right paracolic gutter, particularly at the site of mobilization of the hepatic flexure. There was no pulsatile bleeding, just a small amount of oozing. Two 10 flat Jackson-Pratt drains were left, the superior most placed along the right paracolic gutter extending up to the region of the hepatic flexure and the second placed in the lower retroperitoneum at the site of abscess. These exited through separate stab incisions and were secured in place at the skin site with silk sutures. The wound was irrigated and the irrigant suctioned out. Again, sponge, needle, and instrument counts were correct, and the fascia was closed with a deep layer of running #1 Vicryl and more superficial layer of running #1 PDS. The subcuticular tissues were irrigated and skin edges were approximated with skin staples. A sterile dressing was applied. The patient was awakened and returned to recovery in stable condition.
