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.
Medical Transcription Samples
Medical Transcription Samples
