PREOPERATIVE DIAGNOSIS:
Ulcerative colitis.
POSTOPERATIVE DIAGNOSIS:
Ulcerative colitis.
OPERATION:
Laparoscopic total abdominal colectomy with an
end ileostomy and a Hartmann pouch.
ANESTHESIA:
General.
CLINICAL INDICATIONS:
The patient is an 18-year-old male with over two
years' history of ulcerative colitis that had not responded to medical therapy. He has
required hospitalization for total parenteral nutrition because the patient had severe
colitis and malnutrition. He was advised to undergo a colectomy. We decided to
perform a total abdominal colectomy, leaving the rectum in place because he was too
malnourished to attempt a pouch procedure in one stage. He agreed to proceed with
the surgery and signed appropriate consent.
DESCRIPTION OF PROCEDURE: The operation was performed with the patient under
general anesthesia in the modified lithotomy position with the legs in Allen stirrups. The
pneumatic boots were used for deep vein thrombosis prophylaxis. The abdomen was
prepared with Betadine and draped sterilely. We used a gram of cefoxitin for antibiotic
prophylaxis. We started the operation by placing a Hassan trocar in the infraumbilical
area. We created a pneumoperitoneum and inspected the peritoneal cavity. The small
bowel looked normal. The colon was quite inflamed. We placed a 12-mm trocar in the
right lower quadrant at the site that had been previously marked for the ileostomy. Then
we placed three additional 5-mm trocars in the right upper quadrant, left upper quadrant
and left lower quadrant.
We started the operation by identifying the ileocolic vessels. They were skeletonized
and divided with the LigaSure. We then started lifting the mesentery of the right colon
from the retroperitoneal attachments and from the duodenum, using blunt dissection and
the LigaSure. The mesentery of the colon was then completely lifted. We continued
dividing the vascular portion of the mesentery toward the middle colic vessels. The
duodenum was brushed posteriorly. We then turned our attention to the gastrocolic
omentum. This was divided to the right of the midline. The omentum was then divided
sequentially with the LigaSure towards the hepatic flexure. The right side of the colon
was this way mobilized. The hepatic flexure was taken down and the attachments of the
right colon to the right abdominal wall were similarly taken down with the LigaSure.
Eventually the entire right colon was lifted from the retroperitoneal attachments.
We then turned our attention to the gastrocolic omentum outside the gastroepiploic
arcade and continued taking the gastrocolic vessels toward the splenic flexure. The
colon was quite inflamed and it was difficult to mobilize, but we were able to get all the
way down towards the splenic flexure. Then the middle colic vessels were skeletonized
and divided with the LigaSure. Then the avascular portion of the mesentery of the
transverse colon was divided until we reached close to the splenic flexure. At this point,
we turned our attention to the attachments of the sigmoid colon to the lateral pelvic
sidewall. These were opened with electrocautery and then using the LigaSure, we cut
the attachments of the left colon toward the left gutter. We continued dividing from the
sigmoid colon toward the splenic flexure. Eventually we lifted the mesentery of the left
colon from the retroperitoneal attachments, exposing the left ureter. Finally, the splenic
flexure was completely taken down. The avascular portion of the mesentery of the colon
and the splenic flexure was divided and the left colic vessels were then identified. They
were skeletonized and divided with a fire of the LigaSure. We continued dividing the
avascular portion of the mesentery of the descending colon until we reached the
superior rectal vessels.
At this point, we made a supraumbilical incision. This was carried through the
subcutaneous tissue until we reached the anterior rectus sheath. This was opened
transversely. Then we raised flaps behind the superior rectal sheath anteriorly and
inferiorly. The rectus muscles were split in the midline, and the peritoneum was entered.
We used the Alexis retractor for exposure. We identified the ileocecal region. We
divided the ileum flush with the cecum and divided the mesentery of the terminal ileum.
The terminal ileum was dropped into the peritoneal cavity and the cecum was then
exteriorized. The colon was very carefully retrieved through the incision. It was quite
large and inflamed. We were able to exteriorize it completely to the sigmoid colon. After
the colon was exteriorized, there was an area that perforated from the traction of the
specimen itself and there was some contamination of the outside, but not the peritoneal
cavity.
We then divided the mesentery of the sigmoid colon close to the bowel using sequential
bites of the LigaSure, and continued dividing the mesentery this way close to the colon
until we reached the junction of the upper and mid rectum. At this point, the bowel was
less inflamed to the point where I felt that it would be possible to transect it with a
contoured stapler. The bowel was skeletonized and then divided with a fire of the
contoured stapler. This was again at the level of the mid rectum. The specimen was
sent to Pathology. The pelvis was extensively irrigated with saline. We saw no
contamination or bleeding.
The end of the terminal ileum was then identified. The trocar site in the right lower
quadrant was enlarged, and the terminal ileum was brought through this same opening.
The opening for the Hassan trocar in the infraumbilical area was closed with 0 Dexon.
The pelvis was again irrigated. The peritoneum was closed with running 0 Dexon. The
anterior rectus sheath was approximated with running #1 Maxon. The subcutaneous
tissue was irrigated with saline and was partially approximated with nylons, but they
were not completely tied. Before closing the suprapubic incision, I had placed a 10 flat
French Jackson-Pratt drain in the pelvis and brought this through the trocar site in the
left lower quadrant. The trocar sites in the left and right upper quadrants were closed
with Biosyn subcuticular suture. The same thing was used to close the skin in the
infraumbilical trocar incision. The ileostomy was then matured in a Brooke fashion using
interrupted 4-0 Dexon stitches.
COUNTS:
two.
Sponge and instrument counts were correct times
ESTIMATED BLOOD LOSS:
Minimal.
DISPOSITION:
The patient tolerated the procedure well and was
transferred to the Post-Anesthesia Care Unit in a stable condition.
ASSISTANT SURGEON(S):
Elizabeth Wick, M.D.
If the assistant surgeon is other than a qualified resident, I certify that the services were
medically necessary and there was no qualified resident available to perform the
services.