Case -T7-2B OPERATIVE REPORT, HEMICOLECTOMY

Essay

Case
-T7-2B OPERATIVE REPORT, HEMICOLECTOMY
LOCATION: Inpatient, Hospital
PATIENT: Cecil Graft
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Hepatic flexure tumor
POSTOPERATIVE DIAGNOSIS: Hepatic flexure tumor
PROCEDURE PERFORMED: Right hemicolectomy
HISTORY: This gentleman has a tumor of his hepatic flexure. He has very severe medical problems. The family and the patient wanted to proceed with surgery knowing the huge risks involved.
PROCEDURE: The patient was given a general anesthetic. He had a Swan-Ganz catheter and an arterial line inserted by anesthesia. He was then prepped and draped in the supine fashion. He had had a Foley catheter inserted prior to coming to the operating room. I made a midline skin incision going to the left of the umbilicus. I worked my way into the abdomen and found that there was a very mobile tumor in the hepatic flexure. The liver itself looked fine. There were some adhesions in the right upper quadrant secondary to what I believe is a previous cholecystectomy. I mobilized the right colon along the white line of Toldt and mobilized all the adhesions in the right upper quadrant. I then found that the tumor was right in the hepatic flexure. Once I mobilized the tumor, it was obvious that if this had grown outside of the bowel, it would have eroded right into the duodenum, which was right below it. However, there was no sign that this tumor was outside of the colon. There were no palpable lymph nodes, and it was not stuck to the liver, pancreas, or duodenum. It was freely inside in the bowel. I then mobilized the omentum off of this colon. Then I elected to try to do a segmental colon resection, which I at first thought would be a simpler, easier operation for this gentleman. I used the stapler and went distal and proximal to the tumor, and then I went through the mesentery with right angles. I had my assistant open up the bowel to prove that we had the tumor obviously, but also to make sure we had good margins, which we obviously did. However, once I had this out, I found that I really did not have a lot of right colon left. The blood supply to the right colon was poorer than the blood supply to the terminal ileum, so I elected to just do an extended right hemicolectomy and be done with it. I continued my dissection all the way down and went through the terminal ileum with the stapler and went through the mesentery with Kelly's and removed the rest of the right colon so that he, in fact, did have an extended right hemicolectomy. I tied with Vicryl ties. I then brought the two edges of the bowel together. I had mobilized the omentum off of the bowel. I opened up the bowel along the antimesenteric border on both sides and then brought the two edges of bowel together with GIA-75 stapler. Prior to stapling, I had put a distal and a proximal Vicryl stitch so that I could keep the bowel oriented. Prior to firing the stapler, I made sure that the mesentery of the colon and the small bowel were outside of the stapler. Once I fired the stapler, I looked at the bowel itself, and I found that I had an excellent anastomosis. There was excellent blood supply and no tension at all. I closed the hole first using Allis clamps to bring the two edges of the bowel together, and then I used TL-60 stapler and closed the hole off. This gave me an excellent hemostasis again with excellent blood supply and no tension at all. I closed the mesentery with a running Vicryl stitch. I used Hemaseel around the anastomosis. As mentioned, there were no obvious lymph nodes in the mesentery. The liver itself looked fine. I usually do not use NG tubes with right hemicolectomies, but considering that this gentleman is otherwise so ill, I elected to put an NG tube in. We confirmed it within the correct place in the stomach. I then put omentum over the anastomosis and closed with 2-0 Vicryl stitches. I irrigated out the wound with sterile saline and then closed the skin with staples. Telfa, Toppers, and gauze were applied. The patient tolerated this very well and went to the recovery room in good condition.
PATHOLOGY REPORT LATER INDICATED: See Report 7-2C.
T7-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________