Right Hemicolectomy Surgery Sample #1
PREOPERATIVE DIAGNOSIS: Ischemic colitis.
POSTOPERATIVE DIAGNOSIS: Ischemic colitis.
PROCEDURES PERFORMED: Right hemicolectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMENS: Right hemicolon.
INDICATIONS FOR PROCEDURE: This is a gentleman who just underwent a cardiac surgery and now has distended tender abdomen. CAT scan shows a thickened colon on the right side with possible ischemia. The patient is tender on exam. We recommended exploration. Risks, benefits and alternatives have been discussed with his family, who has consented for surgery.
DETAILS OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. After undergoing general anesthesia, his abdomen was prepped and draped in surgical fashion using DuraPrep.
A vertical midline incision was made. Dissection was taken down to the fascia, which was incised with a Bovie, and the peritoneum was entered. The abdomen was explored. The right colon had been ischemic and was recovering. There were some punctate hemorrhages in the right side of the transverse colon consistent with possible embolic events.
The patient also had a very distended sigmoid. Based on our concerns about ischemic colitis, we elected to do right hemicolectomy mobilizing the right colon with a Bovie, transecting it to terminal ileum as well as transverse colon just proximal to the middle colic artery with a GIA stapler. Mesentery was taken with vascular loads and stapler.
Side-to-side functional end-to-end anastomosis was created. The anastomosis was then oversewn with 3-0 silk Lembert, left the mesenteric defect open because it was fairly large and wide and it had been difficult to close.
We ran the bowel in the peritoneum and began our closure with number 1 PDS used on the fascia and staples were used to close the skin. Dressing was applied. The patient was awakened and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.
Right Hemicolectomy Surgery Sample #2
PREOPERATIVE DIAGNOSIS: Cecal mass.
POSTOPERATIVE DIAGNOSIS: Hepatic flexure colonic mass.
PROCEDURE PERFORMED: Right hemicolectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
SPECIMEN: Right colon.
COMPLICATIONS: None.
DRAINS: A 15-French round drain placed within the gallbladder bed fossa.
FINDINGS: Upon entry into the abdominal cavity, a hepatic flexure mass could be easily palpated. Visualization revealed that the mass had extended into the fundus of the gallbladder and also into the second portion of the duodenum.
During the course of our blunt dissection, we were able to take off this area of tumor from the gallbladder bed and also from the second portion of the duodenum without injuring these structures. No other abdominal pathology was noted.
INDICATIONS FOR PROCEDURE: The patient is an (XX)-year-old male who presented to the emergency room complaining of abdominal pain and loss of appetite. On workup, his abdominal x-ray showed multiple dilated loops of small bowel and we then initially placed a nasogastric tube for decompression.
Upon questioning, the patient denied any change in his bowel habits or weight loss. Previously colonoscopy, multiple years ago, did not reveal any colonic pathology at that time and he reportedly had no family history of colon cancer. The patient also denied any history of diverticular disease.
Physical examination did not reveal any hernias, and he had a mildly tender abdomen that was quite distended. A CT of the abdomen and pelvis was then obtained, which did reveal a right-sided colonic lesion secondarily causing what looked to be a bowel obstruction. However, upon further review, the patient basically had a large bowel obstruction due to this right-sided colon lesion.
The patient was given IV fluid resuscitation, brought into the hospital and given antibiotics. The imaging findings were discussed with the patient and his family, and they were told that we would be preparing the patient for a right hemicolectomy the following day. All of the risks, benefits and alternatives to the procedure were described in detail to the patient and his family by the attending. Operative consent was signed and placed upon the chart.
DETAILS OF PROCEDURE: The patient was taken to the operating room and placed in supine position. Bilateral lower extremity athrombics were placed. A nasogastric tube along with a Foley catheter had already been placed the previous day. The patient’s abdomen was then sterilely prepped and draped in a standard surgical fashion.
A right paramedian incision was then made in a vertical fashion. The incision was extended from about 2 fingerbreadths below the costal margin to midway between the pubis and iliac crest. This incision was then deepened through the subcutaneous tissues with Bovie electrocautery. Peritoneal cavity was entered. A Bookwalter retractor device was then placed. The small bowel contents were then eviscerated. A moist towel was placed. A hepatic flexure mass was then easily palpated.
At this time, we went ahead and turned our attention at mobilizing the colon for future resection. Using electrocautery, the colon was then freed from its peritoneal attachments along the line of Toldt from the terminal ileum to just distal to the hepatic flexure. During the course of our dissection around the hepatic flexure, we noted that the tumor was eroding into a portion of the fundus of the gallbladder and also there was some tumor burden on the second portion of the duodenum. We were able to mobilize this with blunt dissection and there were no injuries noted to the duodenum or to the gallbladder fundus.
Once this was completed, the colon was then easily mobilized. Points of transection were then selected proximally and distally. The proximal resection was 5 cm from the ileocecal valve and our distal transection point was in the proximal one-third of the transverse colon. Once this was determined, the bowel was then divided with the linear cutting stapler in these two regions. The peritoneum overlying this area was then scored with electrocautery and the ileocolic artery was identified, doubly ligated with 2-0 silk sutures and transected. The main trunk to the middle colic was similarly identified and ligated. The remaining mesentery and all associated nodal tissue was then divided and swept down with the specimen.
The specimen was then removed and sent to pathology for examination. Hemostasis was checked in the operative field and shown to be intact. The two ends of the bowel were then checked and found to be viable with excellent blood supply present. At this time, we went ahead and proceeded with a staple anastomosis. The proximal and distal segments of the bowel were then brought into apposition and found to lie comfortably next to each other with no torsion.
Enterotomies were then made at the antimesenteric borders and then a linear cutting stapler was inserted and fired. Hemostasis was checked along the staple line within the lumen and shown to be intact. The enterotomies were then closed with a TA-60 stapler. The staple line was then reinforced with several interrupted 3-0 silk Lembert sutures. The anastomosis was checked and found to be intact and widely patent. The mesenteric defect was then closed with figure-of-eight 3-0 silk sutures. The abdominal cavity was then copiously irrigated with warm normal saline and hemostasis was checked.
Once this was completed, we then placed a 15-French round drain within the gallbladder bed fossa and exited in the right lower quadrant. The drain was anchored into place with a 3-0 silk suture. The peritoneum was then closed with a running stitch of 0 Vicryl. The fascia was then closed with a running 0 Prolene suture. The subcutaneous tissues were irrigated and reapproximated with running 3-0 Vicryl. The skin was reapproximated with skin staples. Iodoform wicks were placed intermittently between the staples also. Dry sterile dressing was placed and the JP drain was hooked to bulb suction. All instrument, sponge and needle counts were correct at the end of the case.
