DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Recurrent sigmoid diverticulitis.
2. Retroperitoneal cyst.
3. Umbilical hernia.
POSTOPERATIVE DIAGNOSES:
1. Recurrent sigmoid diverticulitis.
2. Retroperitoneal cyst.
3. Umbilical hernia.
OPERATION PERFORMED:
Open low anterior resection, repair of umbilical hernia.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who has had four documented episodes of diverticulitis on CAT scan. He is now recommended to undergo elective sigmoid resection. Recent CT scan was also noted to have a retroperitoneal cyst in the retrocecal area. We decided to explore this as well.
FINDINGS AND DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room and placed in the supine position. After adequate induction of general anesthesia, he was placed in the lithotomy position. Sequential compression devices, TED stockings, and Foley catheter were placed and intravenous antibiotics were administered.
A rigid proctosigmoidoscopy was first performed, and the rectum was cleared of stool. A vertical midline incision was then made up to the umbilicus. Dissection was carried through the subcutaneous tissue down to the fascia, which was dissected sharply and opened for the length of the incision.
A Bookwalter retractor was assembled. The abdomen was then explored. The small bowel was normal. Noted that the sigmoid was not attached to the normal lateral pelvic and lateral sidewall. The entire mesosigmoid was actually within the midline of the abdomen and the tenia densely adherent to the root of the small bowel mesentery. The small bowel was packed out of the way. The sigmoid was then carefully mobilized off of these mesenteric attachments until it was completely free.
As noted again, there were absolutely no attachments to the lateral sidewall. The cecum was first mobilized. The retroperitoneal binder was explored. There was no obvious mass or cyst in this location. The sigmoid was very redundant. There were multiple loops of redundant sigmoid and one which was densely adherent to the lateral pelvic sidewall. It was firm and indurated here and clearly a site of prior perforation. This was taken off sharply.
At this point, this site was chosen for the proximal resection margin. There was healthy bowel with very mild diverticular disease. The bowel here was divided with an auto purse stringer. The anvil of a 29 mm stapler was then placed and secured. The mesentery was divided with LigaSure device. Because there was so much redundant sigmoid and because of the abnormal attachments, we did not even have to take the inferior mesenteric pedicle. We came down on the medial side of it with the LigaSure device.
We did divide the superior rectal artery, which was ligated with 2-0 Vicryl suture. The hypogastric nerves were identified and preserved. The presacral space was entered. Below the sacral promontory, the mesorectum was then clamped and divided and ligated with LigaSure device and 2-0 Vicryl sutures. This site was chosen for division of the rectum. The TA60 stapler was fired. The specimen was then passed off for further pathologic evaluation.
The abdomen was then thoroughly explored again. Hemostasis was achieved. The left ureter was identified. Where we had taken off of the pelvic sidewall, we took some peritoneum with it. We therefore gave an amp of indigo carmine with no extravasation. The anastomosis was then performed with transanal end-to-end anastomosis using 29 mm stapler. On insufflation of the anastomosis, there was a very small air leak anteriorly. The anterior staple line was therefore oversewn with interrupted sutures of 4-0 silk.
Through a separate stab incision in the right lower quadrant, a 10 mm Jackson-Pratt drain was brought through and placed in the pelvis. The abdomen was thoroughly irrigated with antibiotic solution. Seprafilm was placed in the subfascial location. The fascia was closed with a running continuous suture of looped #1 PDS repairing the umbilical hernia at the same time.
The subcutaneous tissue was irrigated with antibiotic solution. The skin was closed with skin clips. The patient tolerated the procedure well. There were no complications. Postoperatively, he was extubated and transferred to recovery room in stable condition.
