PREOPERATIVE DIAGNOSIS: Small bowel obstruction.
POSTOPERATIVE DIAGNOSIS: Small bowel obstruction with distal jejunum mass suspicious for carcinoma.
PROCEDURE PERFORMED: Exploratory laparotomy with small bowel resection.
FINDINGS: The patient had a near-obstructing tumor in her distal jejunum. The patient did have dilated small bowel proximal to this tumor. She did, however, have air and fluid beyond the tumor and she had air and stool in her colon. This area was resected.
DESCRIPTION OF THE OPERATION: The patient was taken to the operating room and placed in the supine position. The patient was administered general endotracheal anesthesia. During induction the patient did have a small amount of emesis. The patient’s skin was then prepped and she was draped in the usual sterile fashion.
A midline celiotomy incision was made and the abdomen was entered without difficulty. The patient had significantly dilated small bowel from the ligament of Treitz distally to the distal jejunum. In this area the patient had evidence of a mass with significant mesenteric adenopathy. The small bowel distal to the mass was also dilated but it was smaller in caliber. She also had a dilated colon with air in the colon. The mass was excised. The small intestine approximately 10 cm on either side of the mass was transected using a GIA-55 stapler with medium staples. Both staple lines were oversewn with a 3-0 Surgipro suture. The patient then had a wide mesenteric excision to include all of the palpable lymph nodes. The specimen was removed and sent to pathology. The mesentery was tied off with 0 silk ties. The patient then underwent a side-to-side functional end-to-end anastomosis. The patient had an anterior layer of 3-0 GI silk Lemberts placed. Bowel clamps were placed proximally and the small bowel was entered. The patient had a running fullthickness anastomosis performed with 3-0 Maxon suture. An additional anterior layer of 3-0 GI silk Lemberts was placed. The mesenteric defect was closed using a 3-0 Polysorb suture.
The abdomen was then irrigated copiously and hemostasis was achieved. The fascia was approximated with a #1 looped Maxon in a running fashion with interrupted 0 Vicryl sutures. The patient also had 4 retention sutures placed given her preoperative steroid use. The wound was irrigated and the skin was closed with staples. The patient had a sterile dressing applied.
Given the patient’s preoperative left lower lobe infiltrate as well as the potential aspiration during induction, the patient was transported to the intensive care unit intubated. She was in stable condition.