PREOPERATIVE DIAGNOSIS: Medically refractory ulcerative colitis.
POSTOPERATIVE DIAGNOSIS: Medically refractory ulcerative colitis.
OPERATIONS PERFORMED:
1. Laparoscopic total abdominal colectomy with end ileostomy.
2. Repair of bladder injury.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
IV FLUIDS: 3800 mL.
ESTIMATED BLOOD LOSS: Less than 50 mL.
URINE OUTPUT: 650 mL.
POSTOPERATIVE CONDITION: Stable.
INDICATIONS FOR SURGERY: The patient is a (XX)-year-old female with medically refractory ulcerative colitis involving primarily the rectum and rectosigmoid. The patient has been unresponsive to steroids. I have had a long discussion with the patient in the office concerning optimal management. I recommended she undergo total abdominal colectomy with end ileostomy. I informed the patient that this could be potentially performed laparoscopically but that there was a high risk of converting to an open procedure. The patient understood and agreed to proceed.
DESCRIPTION OF OPERATION: After obtaining informed consent, the patient was taken to the operating room and placed on the operating table in the supine position. Compression boots were applied. Perioperative IV antibiotics were given. Subcutaneous heparin was administered. The patient then underwent general endotracheal anesthesia. Bean bag was then desufflated. She was then prepped and draped in the usual sterile manner. Attention was first paid to her umbilicus where a supraumbilical incision was made with an 11 blade. Dissection down to the abdominal fascia was performed. A 12 mm trocar was then placed in the Hasson fashion. Gas insufflation was obtained.
The 10 mm, 30-degree laparoscope was then placed into the abdomen. The abdomen was then briefly explored and no abnormalities were seen. Four 5 mm trocars were then placed under direct vision, two in the left lower quadrant and two in the right lower quadrant. Dissection was begun at the cecum. The cecum was identified and retracted inferiorly and laterally. The ileocolic vessels were identified. These were then taken carefully with 5 mm LigaSure device. In the retroperitoneal plane, below the level of the colonic mesentery, the duodenum was identified. Dissection was carried out to the lateral pelvic sidewall and up towards the hepatic flexure. The proximal transverse colon was then identified. The greater omentum was removed from the proximal transverse colon.
Dissection was then performed at the ileocecal junction up the right pelvic sidewall to meet with our medial dissection. The hepatic flexure was then mobilized carefully with a combination of Bovie electrocautery as well as a LigaSure device. We then began dissection more distally from our transverse colon. The gastrocolic ligament was then identified and divided with Bovie electrocautery separating the omentum from the transverse colon. This was continued toward the splenic flexure. We then retracted our transverse colon superiorly and anteriorly and then identified the middle colic vasculature as well as the mesentery in this area. This was then transected carefully with LigaSure device. We then continued our dissection through the gastrocolic ligament towards the splenic flexure.
Once the splenic flexure was reached, we then began our left colon dissection. We removed the rectosigmoid from the pelvis. We then retracted the rectosigmoid superiorly and identified the IMA pedicle beneath, of which we performed a dissection with Bovie electrocautery. We then gained access in the retroperitoneum underneath the IMA pedicle and then identified our left ureter. Dissection underneath this plane was then performed laterally and inferiorly to move the ureter out of the way. We then made a window distal to the IMA pedicle and then transected our IMA carefully with a 5 mm LigaSure device.
We continued our dissection towards the splenic flexure between the colonic mesentery and the retroperitoneal structure staying above Gerota’s fascia. We then carried this dissection laterally onto the left lateral pelvic sidewall. We then dissected up the left lateral pelvic sidewall up towards the splenic flexure with Bovie electrocautery freeing our colon segment from the retroperitoneal structures. The splenic flexure was then taken down carefully with a combination of Bovie electrocautery as well as a LigaSure device. We then reassessed where our dissection planes were. We had some colonic mesentery to primarily the splenic flexure and distal transverse colon to go. This was then taken down with the LigaSure device carefully.
Once our colon was freely mobilized, we then did the open portion of the procedure. We made a Pfannenstiel incision in a skin crease with a 10 blade. The subcutaneous tissue was then divided with Bovie electrocautery. Dissection down to the anterior fascia was then performed. This was done open in a curvilinear fashion. The dissection plane was then performed below the fascia and above the rectus muscle superiorly and then inferiorly. We then opened our muscle and peritoneum in the midline.
Dissection was continued proximally throughout the length of our wound and then distally. There was a lot of fat distally and we then created a very small hole in the bladder. This was repaired with multiple interrupted 3-0 Vicryl sutures. We then placed a protractor drape. Our rectosigmoid was identified and the colon was then pulled out through the incision. The remaining mesentery to the rectosigmoid junction was then taken between Kocher clamps and tied with 0 Vicryl sutures. The colon was then transected just proximal to the rectosigmoid junction with a TX-60 stapling device. We then removed the remainder of the colon from the abdomen. The ileocecal junction was identified. The mesentery was completely taken at that point between Kocher clamps and 0 Vicryl sutures.
We passed a specimen off the field. It was opened and examined. There was no evidence of neoplasia, but it did have a significant amount of distal inflammatory change. We then made our ileostomy aperture. A small skin disc was removed with a cautery device. Dissection through subcutaneous tissue was performed down to the anterior fascial sheath. This was then opened and divided. The muscle was split and the posterior sheath was then opened. We then passed our terminal ileum up through the aperture. There was absolutely no tension. We then irrigated our wound. We then went back laparoscopically to ensure that our ileostomy had the correct orientation. It was twisted 180 degrees, which was then corrected.
We then closed the Pfannenstiel incision. The peritoneum was closed with a running 0 Vicryl suture. The muscle was closed with three interrupted figure-of-eight 0 Vicryl sutures. The fascia was closed with a running 0 Vicryl suture. The wound was irrigated copiously with saline. The subcutaneous tissue was closed with multiple interrupted 3-0 Vicryl sutures. The skin was then closed with a running 4-0 Monocryl. The abdomen was then desufflated. The trocars were then removed. The wounds were irrigated and closed. The umbilical wound was closed with 0 Vicryl suture that had been previously placed. The skin was then closed at each site with 4-0 Monocryl suture. Dermabond was then applied. The stoma was matured in a Brooke fashion with multiple interrupted 3-0 chromic sutures. The stoma appliance was applied. The patient was then awakened, extubated, and taken to the recovery room in good condition.
