1
Documentation Dissection
PREOPERATIVE DIAGNOSIS: Recurrent complicated sigmoid diverticulitis.
POSTOPERATIVE DIAGNOSIS: Recurrent complicated sigmoid diverticulitis
|1|
.
OPERATION PE RFORMED: Laparoscopic-assisted sigmoid colectomy
|2|
.
ANESTHESIA: General anesthesia with endotracheal intubation.
IN DICATIO NS: _________ ___ is a __ __-year-old woman who presents with recurrent and now complicated sigmoid
diverticulitis. She was advised of her treatment options and elected to proceed with laparoscopic sigmoid colectomy. The nature of
her problem and proposed treatment, rationale, risks, and alternatives were discussed with her and she agreed to proceed.
INTRAOPERATIVE FINDINGS:
1. Evidence of the extensive diverticulosis involving the sigmoid colon with evidence of previous acute inflammatory processes
with scarring and induration of the sigmoid colon.
2. No other evidence of intra-abdominal pathology.
PROCEDU RE: The patient is brought to the operating suite where she was placed under general anesthesia with endotracheal
intubation. Her abdomen was then prepped and draped in usual sterile fashion. The rectum was instilled with Betadine as well.
Access to the abdomen was made through a 5 mm incision in the right upper quadrant. The Veress needle was inserted through
this incision and verified to be in intraperitoneal position. The abdomen was insufflated to 15 cm of water with CO2 and a 5 mm
trocar was placed
|3|
. Video peritonoscopy ensued.
There was no evidence of iatrogenic injury upon gaining access to the abdomen. A 12 mm trocar was then placed in the right lower
quadrant. A 5 mm trocar in the left upper quadrant and a 5 mm trocar in the left mid abdomen. We then thoroughly explored
the abdomen. We easily identified the sigmoid colon. There was no associated structures adherent to the sigmoid colon other than
some post inflammatory adhesions of the sigmoid colon to the lateral abdominal lateral pelvic sidewall.
The patient was positioned in steep Trendelenburg. This allowed the hollow viscus to fa ll out of the pelvis. We then began the
procedure by identifying the junction of the rectosigmoid. At this point the mesentery was marked as this would be the point that
would be our distal point of resection
|4|
. We then went ahead and took down the lateral peritoneal attachments of the sigmoid
colon all way up to the level of the splenic flexure. The colon was medialized.
We could easily identify the left ureter as this patient was quite thin. It was identified through t he peritoneum and preserved
without injury during the entire course of this procedure. We then using the Harmonic scalpel we took down the mesentery of
the sigmoid colon. This was done with a Harmonic scalpel to the point where we reached the descending branch of the inferior
mesenteric artery that was taken with a vascular load of the stapler.
Having then found pliable soft bowel proximal to the sigmoid colon and roughly at the level of the junction of the descending
colon and sigmoid colon, we at that point decided that would be the point of proximal division of the bowel
|5|
. We then enlarged
the left lower quadrant 5 mm trocar to be about a 3 cm incision with a muscle-splitting technique. The bowel was delivered out of
this incision. We found a nice soft plane on the bowel at which point a pursestring device was placed on the bowel, and the bowel
amputated just distal to this pursestring device
|6|
.
We then went ahead and placed a 29 mm EEA anvil into this and secured the pursestring. Unfortunately, we found a small
diverticulum at our staple line. For this reason, we went ahead and went up another couple of centimeters and once again placed
a pursestring on the bowel and replaced the 29 mm EEA anvil into the distal bowel. The pursestring was secured. There was no
diverticulum anywhere near t he anvil. We then went ahead and inspected the abdominal cavity. We then went ahead and placed
the descending colon back into the abdominal cavity. The fascia from the left lower quadrant incision was closed with a 1-0 Vicryl
suture in a running fashion. A sterile gauze was placed in the wound. We then reinsufflated the abdomen. At this point we noticed
that there was a small burn from the 5 mm laparoscopic on the abdominal wall juxtaposed to her left lower quadrant incision.
