p.jonmd.us

Procedure Performed: 

Exploratory laparotomy with extensive enterolysis, drainage of right retroperitoneal abscess, sigmoid colectomy with end colostomy (Hartmann procedure), repair of serosal injuries to small bowel and ascending colon, abdominal washout, placement of three closed-suction drains, maturation of end colostomy, and application of wound vacuum-assisted closure (VAC) to midline incision.

Intraoperative Findings:

Upon opening the midline incision, copious feculent fluid was encountered, primarily emanating from the pelvis. Extensive adhesions and enterolysis were required to free the small bowel. The small bowel appeared grossly clean without gross contamination within the mesenteric folds. A large right retroperitoneal abscess lateral to the ascending colon was encountered and drained; the previously placed interventional radiology drain was removed. No leak was identified from the cecum or appendiceal stump. The pelvic source of contamination was a densely adherent phlegmon involving the sigmoid colon and rectum with extensive spillage of formed soft stool, making it difficult to distinguish intraluminal from extraluminal contamination. The descending and proximal sigmoid colon were identifiable, but the distal sigmoid and rectum were obliterated within the pelvic phlegmon.

**Postoperative Diagnosis:**  

Same as preoperative, with feculent phlegmon and perforation involving the sigmoid colon/rectum in the pelvis; right retroperitoneal abscess; multiple serosal injuries to small bowel and ascending colon repaired intraoperatively.

**Procedure Performed:**  

Exploratory laparotomy with extensive enterolysis, drainage of right retroperitoneal abscess, sigmoid colectomy with end colostomy (Hartmann procedure), repair of serosal injuries to small bowel and ascending colon, abdominal washout, placement of three closed-suction drains, maturation of end colostomy, and application of wound vacuum-assisted closure (VAC) to midline incision.

**Indications:**  

The patient presented with ongoing intra-abdominal contamination evidenced by feculent fluid draining from the inferior aspect of the prior midline incision. CT imaging demonstrated a right retroperitoneal abscess with an indwelling percutaneous drain. Given the clinical picture of feculent peritonitis and suspected pelvic source of perforation (likely related to recent appendectomy or diverticular disease), surgical exploration, source control, and diversion were indicated.

**Intraoperative Findings:**  

Upon opening the midline incision, copious feculent fluid was encountered, primarily emanating from the pelvis. Extensive adhesions and enterolysis were required to free the small bowel. The small bowel appeared grossly clean without gross contamination within the mesenteric folds. A large right retroperitoneal abscess lateral to the ascending colon was encountered and drained; the previously placed interventional radiology drain was removed. No leak was identified from the cecum or appendiceal stump. The pelvic source of contamination was a densely adherent phlegmon involving the sigmoid colon and rectum with extensive spillage of formed soft stool, making it difficult to distinguish intraluminal from extraluminal contamination. The descending and proximal sigmoid colon were identifiable, but the distal sigmoid and rectum were obliterated within the pelvic phlegmon.

**Procedure Description:**  

The patient was placed in the supine position. After induction of general anesthesia, the abdomen was prepped and draped in sterile fashion. A pre-procedural timeout was performed to confirm the correct patient, site, and procedure. The patient was receiving scheduled intravenous antibiotics.

The midline incision was reopened by dividing the previously placed fascial sutures. Copious feculent fluid was suctioned from the peritoneal cavity, with the majority originating from the pelvis. Extensive enterolysis was performed to free the small bowel from the anterior abdominal wall and from interloop adhesions. The right retroperitoneal abscess was entered by incising the peritoneum lateral to the ascending colon; purulent and feculent material was suctioned out.

The cecum was mobilized and carefully inspected; no leak was identified from the recent appendectomy site. Attention was then turned to the pelvis, where dense inflammation and phlegmon obscured normal anatomy. The mesentery of the sigmoid colon was followed distally into the pelvis. Using a Contour stapler, the sigmoid colon was transected proximally. Due to the lack of a first assistant at the start of the case, Dr. Harvinderpal Singh was called in to provide much needed assistance. Together, the sigmoid mesentery was sequentially divided and the dissection carried into the pelvis to the level of the cul-de-sac. A second firing of the Contour stapler was used to transect the rectum, completing the resection of the diseased sigmoid and proximal rectum.

To ensure adequate length for colostomy maturation, the descending colon was further mobilized by incising the white line of Toldt laterally and reflecting it medially. The small bowel and ascending colon were re-inspected. Three areas of compromised serosa on the small intestine and one on the ascending colon were repaired with interrupted 3-0 Vicryl Lembert sutures.

The abdomen was generously irrigated with warm normal saline. Hemostasis was confirmed. Three 19-French Blake drains were placed through new stab incisions: one in the right upper quadrant to drain the right upper abdomen, one in the right lower quadrant to drain the pelvis, and one in the left upper quadrant to drain the left upper quadrant.

A quarter-sized circular incision was created in the left lower quadrant and carried through the abdominal wall to allow easy passage of two fingers. The proximal end of the descending colon was brought through this site without tension.

The midline fascia was closed with a running double-stranded 1-PDS suture. The subcutaneous tissues and skin were irrigated and hemostasis confirmed. The wound was covered before the colostomy was opened and matured to the skin. A colostomy bag was applied before the midline wound was re-exposed to apply the wound VAC. 

 The patient was hemodynamically stable throughout the procedure. She was subsequently transferred to the [PACU/ICU] in stable condition.

**Estimated Blood Loss:**  

[XX] mL (minimal to moderate)

**Fluids/Blood Products:**  

[Specify if provided; otherwise: Crystalloid as per anesthesia record. No blood products transfused.]

**Specimens:**  

Sigmoid colon and rectum (sent to pathology)

**Drains/Tubes:**  

Three 19-French Blake drains (right upper quadrant, right lower quadrant/pelvis, left upper quadrant)

**Counts:**  

Sponge, needle, and instrument counts were correct at the end of the case.

**Complications:**  

None

**Postoperative Plan:**  

- Continue broad-spectrum intravenous antibiotics  

- Wound VAC management per protocol with planned changes  

- Monitor drain output and character  

- Early ambulation and DVT prophylaxis  

- Colostomy care and education  

- Advance diet as tolerated once bowel function returns  

- Follow-up CT or clinical evaluation as indicated for ongoing sepsis  

[Your Name], MD  

Attending Surgeon