PREOPERATIVE DIAGNOSIS: Large-bowel obstruction with probable rectal cancer.
POSTOPERATIVE DIAGNOSIS: Large-bowel obstruction with probable rectal cancer.
Exploratory laparotomy with total abdominal colectomy and J-pouch loop ileorectal anastomosis.
Diverting loop ileostomy.
FINDINGS: The patient had an obstructing tumor just above the peritoneal reflection. On rigid proctoscopy, this was at approximately 15 cm. The patient had a significantly distended colon, with the cecum having several areas of deserosalization. This necessitated a total colectomy.
DESCRIPTION OF THE OPERATION: The patient was taken to the operating room and placed in the low lithotomy position. The patient was administered general endotracheal anesthesia. A rigid proctoscopy was performed and the patient was noted to have an obstructing tumor at approximately 15 cm from the anal verge. The patient?s abdomen was then prepped and she was draped in the usual sterile fashion.
A midline incision was made and the abdomen was entered without difficulty. Thorough abdominal exploration was performed. The liver was normal to palpation. The gallbladder was normal to palpation and had no stones. The colon was noted to be massively dilated, with the cecum having several areas of deserosalization due to the significant distention. The patient had an obstructing tumor just above the peritoneal reflection. The right colon was then mobilized along the lateral peritoneal reflection. The right ureter was identified and was spared from injury. The terminal ileum was transected with a GIA stapler with medium staples. The omentum was freed up from the transverse colon and the splenic flexure was completely mobilized. The descending and sigmoid colons were likewise mobilized along the lateral peritoneal reflection. The left ureter was identified and was spared from injury. Dissection was carried down to the rectum. We incised the peritoneal reflection. I was able to get the rectum mobilized so that we had approximately a 5-cm distal margin past the obvious tumor in the rectum. The distal rectum was then transected with a contour stapler with a medium load. The mesentery was taken down and was tied off with a combination of 2-0 silk ties as well as 2-0 suture ligatures on the larger vessels. The specimen was removed and was sent to pathology.
I elected to perform a J-pouch ileorectal anastomosis. The terminal ileum was folded back on itself for approximately 10 cm. We made an enterotomy at the loop portion of the J-pouch and fired a 75-mm stapler, creating a pouch. A 25-mm EEA anvil was then placed through the enterotomy and was secured with a 3-0 Prolene pursestring. The patient had an EEA anastomosis, again using a 25-mm stapler. At the conclusion of the anastomosis, the patient underwent a rigid proctoscopy and the anastomosis was airtight. I elected to perform a diverting loop ileostomy to protect the anastomosis. Just proximal to the anastomosis, the patient had a loop of ileum that was brought out to the skin level through an incision in the right lateral abdominal wall.
The abdomen was then copiously irrigated and hemostasis was achieved. The sponge and needle count was correct. The fascia was reapproximated with a #1 looped PDS in a running fashion. The skin was closed with staples. The loop ileostomy was matured over a #14 French red rubber Robinson catheter. This was performed using 3-0 Vicryl sutures. Prior to abdominal closure, the patient did have a 19-mm Blake drain that was placed down into the pelvis right around the anastomosis. This was secured to the skin with a 3-0 nylon suture. The patient had an ostomy appliance applied. The right chest wall was then prepped and a triple-lumen subclavian line was placed using Seldinger technique. The patient tolerated the procedure well.