PREOPERATIVE DIAGNOSIS: Rectal cancer.
POSTOPERATIVE DIAGNOSES:
1. Rectal cancer.
2. Umbilical hernia.
OPERATIONS PERFORMED:
1. Laparoscopic low anterior resection.
2. Laparoscopic mobilization of splenic flexure.
3. Umbilical hernia repair.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
OPERATIVE FINDINGS:
1. Rectal cancer.
2. Umbilical hernia.
3. Obesity.
SPECIMENS: Sigmoid colon and rectum, proximal and distal margins.
ESTIMATED BLOOD LOSS: 250 mL.
IV FLUIDS: 4000 mL.
ANTIBIOTICS: Ancef and Flagyl.
DRAINS: None.
COMPLICATIONS: None.
POSTOPERATIVE CONDITION: Stable.
INDICATIONS FOR SURGERY: The patient is a very pleasant (XX)-year-old male referred to me for rectal cancer. Recently, the patient developed bright red blood per rectum on the toilet paper and in the stools over the last few months. He underwent colonoscopy, which demonstrated rectal cancer. Biopsies demonstrated invasive colonic adenocarcinoma, moderately differentiated. The patient was then referred to me for further surgical management. The risks, benefits, and alternatives of the procedure were discussed extensively with the patient and family. All of their questions were answered. They agreed to proceed.
DESCRIPTION OF OPERATION: After obtaining informed consent, the patient was taken to the operating room. He was given perioperative IV antibiotics. He was then placed on the operating table in a supine position. Subcutaneous heparin was administered. Compression boots were applied. The patient then underwent general endotracheal anesthesia. A Foley catheter was then placed. The patient was then placed in the lithotomy position. The beanbag was then desufflated. He was then secured to the table. His abdomen was prepped and draped in the usual sterile manner. The umbilicus was opened with a #11 blade. Dissection revealed an umbilical hernia. The subcutaneous tissue was taken off the skin and the contents of the hernia were then placed back into the abdomen. Access to the abdomen was gained with blunt dissection. A single U-shaped 0 Vicryl suture was then placed into the fascia. A 12 mm trocar was then placed into the abdomen and gas insufflation was obtained.
Initial inspection of his abdomen revealed no abnormalities. His liver was examined and there was no evidence of metastatic disease. It was clear that this case was going to be difficult at this point in time as the patient was extremely obese in his abdomen. We then placed him in the Trendelenburg position and mobilized his small bowel out of the pelvis. We then began a dissection over the sacral perimeter beneath the IMA pedicle. This dissection was difficult as his mesentery was extremely thick and the small bowel would not stay out of the pelvis despite multiple maneuvers. I then felt that it was easier to perform a lateral dissection first. His sigmoid colon was then taken off the left pelvic sidewall carefully to preserve the underlying vascular structures as well as the ureter. This dissection was carried along the edge of the retroperitoneum as it attached to the colon, colon mesentery, and the sigmoid colon. This was then taken all the way up to the level of the splenic flexure. We then began our dissection over the distal transverse colon. The gastrocolic ligament was divided and access to the lesser sac was gained. The Harmonic scalpel was used to transect the omentum distally overlying the colon. We then carried this dissection up to the splenic flexure. We then fanned the splenic flexure out and mobilized carefully beyond this over the area of Gerota's fascia overlying the left kidney. This was mobilized all the way up to the level of the inferior border of the pancreas, where the inferior mesenteric vein was identified. We then carried this dissection back down towards the left pelvic sidewall. We identified the left gonadal vessels. Identification of the ureter was difficult because of his fatty tissues. We did eventually identify this and this was preserved and mobilized laterally away from the colon mesentery. We then performed dissection back from the medial side underneath the IMA pedicle leading across where the dissection had been performed laterally. The ureter was kept inferior. The proximal IMA was identified. A window above this was opened with Bovie electrocautery. The overlying peritoneum of the IMA was then opened with a combination of coagulation and Harmonic scalpel. We then transected the IMA carefully with the ligature device. Hemostasis was adequate at that time.
We then performed additional dissection medially up under the mesentery of the sigmoid colon again leading across Gerota's fascia and retroperitoneal structures, which had been mobilized inferiorly from the lateral aspect. Once I felt that the splenic flexure was completely mobilized and that the mobility on the transverse colon, splenic flexure, and descending colon was adequate, we made a small lower midline incision. This was performed with Bovie electrocautery. The fascia was then divided, the midline was identified, and the perineum was then opened. The bladder was carefully mobilized laterally to avoid injury. A medium sized protractor drape was then placed into the abdomen. The colon was then removed from the abdomen. An area between the descending colon and sigmoid colon was identified and chosen as the area to be transected. The mesentery here was divided. The marginal vessels were identified and divided. The marginal vessel had good pulsatile bleeding. These were then clamped and secured with 0 Vicryl sutures. The bowel was then cleaned off and then transected with an automated purse-string device. The ILS-29 anvil was then placed into the descending colon and secured with the previously placed suture. This was then packed away as was the small bowel up into the abdomen, and the pelvic portion of our procedure was then performed.
We had already dissected over the sacral promontory in the presacral plane and this was continued distally with Bovie electrocautery. Care was taken to preserve the fascia appropriate to the rectum. The prerectosacral fascia was then divided to gain access below the level of the tumor. This tumor was palpable. We then performed the lateral dissection along the right and left pelvic sidewalls. Care again was taken to not injure either ureter or vascular structures, but provide adequate margin for our tumor. We then performed this dissection anteriorly as our lateral dissection met. The bladder and anterior structures were then mobilized away from the edge of the colon. Care was taken to preserve those anterior structures. I do not believe we reached the level of the seminal vesicles and they were thus preserved. Dr. Doe then performed proctoscopy to ensure we were well distal to our tumor and we were. The mesentery had thinned in this region and was taken along with the rectum with a single fire of the TX-60 stapling device. The specimen was then removed, opened, and examined along with pathology. The distal margin was approximately 2.6 cm. There was some fibrosis within the mesentery and there was some palpable lymphadenopathy. The abdomen was then irrigated copiously with saline solution. Hemostasis was adequate. We then performed the ILS-29 stapled colorectal anastomosis. There was absolutely no tension on the anastomosis. Hemostasis was adequate. The doughnuts were then examined and found to be complete. The anastomosis was then leak tested under water and there was no leakage. We had to remove the packing from the abdomen. We also removed the protractor drape.
At this point in time, all counts were correct. The fascia was then closed with running 1 PDS suture. The wound was then irrigated copiously with saline solution. The wound was then staple closed. The fascia at the umbilicus was closed with a single 0 Vicryl suture that had been previously placed. All the other trocar sites were then closed with single 4-0 Vicryl or 4-0 Monocryl suture. All the wounds were cleaned and dried and secured with Tegaderm and a sterile gauze dressing. The patient was then awakened, extubated, and taken to recovery room in good condition.
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POSTOPERATIVE DIAGNOSES:
1. Rectal cancer.
2. Umbilical hernia.
OPERATIONS PERFORMED:
1. Laparoscopic low anterior resection.
2. Laparoscopic mobilization of splenic flexure.
3. Umbilical hernia repair.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
OPERATIVE FINDINGS:
1. Rectal cancer.
2. Umbilical hernia.
3. Obesity.
SPECIMENS: Sigmoid colon and rectum, proximal and distal margins.
ESTIMATED BLOOD LOSS: 250 mL.
IV FLUIDS: 4000 mL.
ANTIBIOTICS: Ancef and Flagyl.
DRAINS: None.
COMPLICATIONS: None.
POSTOPERATIVE CONDITION: Stable.
INDICATIONS FOR SURGERY: The patient is a very pleasant (XX)-year-old male referred to me for rectal cancer. Recently, the patient developed bright red blood per rectum on the toilet paper and in the stools over the last few months. He underwent colonoscopy, which demonstrated rectal cancer. Biopsies demonstrated invasive colonic adenocarcinoma, moderately differentiated. The patient was then referred to me for further surgical management. The risks, benefits, and alternatives of the procedure were discussed extensively with the patient and family. All of their questions were answered. They agreed to proceed.
DESCRIPTION OF OPERATION: After obtaining informed consent, the patient was taken to the operating room. He was given perioperative IV antibiotics. He was then placed on the operating table in a supine position. Subcutaneous heparin was administered. Compression boots were applied. The patient then underwent general endotracheal anesthesia. A Foley catheter was then placed. The patient was then placed in the lithotomy position. The beanbag was then desufflated. He was then secured to the table. His abdomen was prepped and draped in the usual sterile manner. The umbilicus was opened with a #11 blade. Dissection revealed an umbilical hernia. The subcutaneous tissue was taken off the skin and the contents of the hernia were then placed back into the abdomen. Access to the abdomen was gained with blunt dissection. A single U-shaped 0 Vicryl suture was then placed into the fascia. A 12 mm trocar was then placed into the abdomen and gas insufflation was obtained.
Initial inspection of his abdomen revealed no abnormalities. His liver was examined and there was no evidence of metastatic disease. It was clear that this case was going to be difficult at this point in time as the patient was extremely obese in his abdomen. We then placed him in the Trendelenburg position and mobilized his small bowel out of the pelvis. We then began a dissection over the sacral perimeter beneath the IMA pedicle. This dissection was difficult as his mesentery was extremely thick and the small bowel would not stay out of the pelvis despite multiple maneuvers. I then felt that it was easier to perform a lateral dissection first. His sigmoid colon was then taken off the left pelvic sidewall carefully to preserve the underlying vascular structures as well as the ureter. This dissection was carried along the edge of the retroperitoneum as it attached to the colon, colon mesentery, and the sigmoid colon. This was then taken all the way up to the level of the splenic flexure. We then began our dissection over the distal transverse colon. The gastrocolic ligament was divided and access to the lesser sac was gained. The Harmonic scalpel was used to transect the omentum distally overlying the colon. We then carried this dissection up to the splenic flexure. We then fanned the splenic flexure out and mobilized carefully beyond this over the area of Gerota's fascia overlying the left kidney. This was mobilized all the way up to the level of the inferior border of the pancreas, where the inferior mesenteric vein was identified. We then carried this dissection back down towards the left pelvic sidewall. We identified the left gonadal vessels. Identification of the ureter was difficult because of his fatty tissues. We did eventually identify this and this was preserved and mobilized laterally away from the colon mesentery. We then performed dissection back from the medial side underneath the IMA pedicle leading across where the dissection had been performed laterally. The ureter was kept inferior. The proximal IMA was identified. A window above this was opened with Bovie electrocautery. The overlying peritoneum of the IMA was then opened with a combination of coagulation and Harmonic scalpel. We then transected the IMA carefully with the ligature device. Hemostasis was adequate at that time.
We then performed additional dissection medially up under the mesentery of the sigmoid colon again leading across Gerota's fascia and retroperitoneal structures, which had been mobilized inferiorly from the lateral aspect. Once I felt that the splenic flexure was completely mobilized and that the mobility on the transverse colon, splenic flexure, and descending colon was adequate, we made a small lower midline incision. This was performed with Bovie electrocautery. The fascia was then divided, the midline was identified, and the perineum was then opened. The bladder was carefully mobilized laterally to avoid injury. A medium sized protractor drape was then placed into the abdomen. The colon was then removed from the abdomen. An area between the descending colon and sigmoid colon was identified and chosen as the area to be transected. The mesentery here was divided. The marginal vessels were identified and divided. The marginal vessel had good pulsatile bleeding. These were then clamped and secured with 0 Vicryl sutures. The bowel was then cleaned off and then transected with an automated purse-string device. The ILS-29 anvil was then placed into the descending colon and secured with the previously placed suture. This was then packed away as was the small bowel up into the abdomen, and the pelvic portion of our procedure was then performed.
We had already dissected over the sacral promontory in the presacral plane and this was continued distally with Bovie electrocautery. Care was taken to preserve the fascia appropriate to the rectum. The prerectosacral fascia was then divided to gain access below the level of the tumor. This tumor was palpable. We then performed the lateral dissection along the right and left pelvic sidewalls. Care again was taken to not injure either ureter or vascular structures, but provide adequate margin for our tumor. We then performed this dissection anteriorly as our lateral dissection met. The bladder and anterior structures were then mobilized away from the edge of the colon. Care was taken to preserve those anterior structures. I do not believe we reached the level of the seminal vesicles and they were thus preserved. Dr. Doe then performed proctoscopy to ensure we were well distal to our tumor and we were. The mesentery had thinned in this region and was taken along with the rectum with a single fire of the TX-60 stapling device. The specimen was then removed, opened, and examined along with pathology. The distal margin was approximately 2.6 cm. There was some fibrosis within the mesentery and there was some palpable lymphadenopathy. The abdomen was then irrigated copiously with saline solution. Hemostasis was adequate. We then performed the ILS-29 stapled colorectal anastomosis. There was absolutely no tension on the anastomosis. Hemostasis was adequate. The doughnuts were then examined and found to be complete. The anastomosis was then leak tested under water and there was no leakage. We had to remove the packing from the abdomen. We also removed the protractor drape.
At this point in time, all counts were correct. The fascia was then closed with running 1 PDS suture. The wound was then irrigated copiously with saline solution. The wound was then staple closed. The fascia at the umbilicus was closed with a single 0 Vicryl suture that had been previously placed. All the other trocar sites were then closed with single 4-0 Vicryl or 4-0 Monocryl suture. All the wounds were cleaned and dried and secured with Tegaderm and a sterile gauze dressing. The patient was then awakened, extubated, and taken to recovery room in good condition.
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