Report from Victoria Hospital
Prince Albert, Saskatchewan, Canada
Attending Physician: Randy Friesen
Admission Date: 2000 December 12

FINDINGS
When we created a pneumoperitoneum it became obvious he had a small umbilical hernia. Laparoscopy revealed dilatation of the entire small bowel, and a moderate amount of serous fluid in the abdominal cavity. We also noted dilatation of the ascending colon and the trasverse colon. No specific cause for the obstruction could be identified laparoscopically.

At laparotomy we found the descending and sigmoid colon to be quite collapsed. The transverse colon was dilated right up to the specific flexure. Finally we were able to identify a very small cicatrizing tumor about 2 to 2.5 cm. in diameter, very close to the spleen. There was no visible or palpable metastatic disease anywhere in the abdomen or pelvis. We opened the bowel in the operating room and found a very small stenotic lesion. Resection margins were 6 to 7 cm. both proximally and distally.

The umbilical hernia was relatively small, but repair was required in order to facilitate proper closure of the abdomen.

PROCEDURE
The patient was supine under general endotracheal anesthesia with routine prepping and draping. A Verres needle was introduced below the umbilicus and with the usual settings and precautions a pneumoperitoneum was created. A 10 cm. trocar was inserted below the umbilicus and a 30 degrease laparoscope was introduced. An additional 5 mm. port was placed suprapubically and a blunt probe was inserted. The above findings were noted. We elected to convert to paparotomy.

A midline incision was made from above the symphysis pubis to the level of the umbilicus. we ran the small bowel from end to end and found no lesion. We then found a collapsed sigmoid and confirmed the dilatation of the trasverse colon. We therefore carried our incision up well above the umbilicus so we could properly examine the splenic flexure. Then we did finally palpate the small tumor described above.

The incision was extended up superiorly to allow exposure of the splenic flexure. The lateral peritoneal attachments of the descending colon were taken down by sharp bipolar cautery scissor dissection. The splenocolic attachments were divided with ties of 3-0 Vicryl for hemostasis. Finally, the splenic flexure was able to be delivered down into the incision. The gastrocolic omentum was also divided with ties of 3-0 Vicryl and we were able to bring the tumor up into the incision. Points of resection were chosen proximally and distally, significantly more then 5 cm. The mesentery was then divided to get some of the blood supply along with the lesion. Ties of 3-5 Vicryl were used. Satinsky clamps were placed proximally and distally after making a colotomy proximally to decompress the bowel, which was quite tense. The bowel was then divided and the specimen was passed off, opened, inspected and placed in Formalin.

A single layer anastomosis was then performed using interrupted sutures of 4-0 Vicryl full thickness. an anti-mesenteric slit was made on the collapsed and to facilitate the anastomosis. There was no tension and there was excellent blood supply. The mesentery was closed with running 2-0 chromic catgut.

Because of the massive dilatation of the small bowel and of the cecum, we considered a colostomy. However, given hi overall excellent health and excellent pre-operative status, and the lack of significant contamination and so on, we elected to perform a decompressing tube cecostomy. This was done by bringing in a #24 Foley catheter through a stab incision in the right lower quadrant and placing it through a cecotomy. There was some spillage of bowel content at this time so we suctioned approximately 1 litre of fluid from the bulb inflated, and then tacked the purse string to the anterior abdominal wall as well. We washed and suctioned copiously at that stage using several litres of warm saline.

The umbilical hernia was then dissected out. The umbilical dimple was freed up from the defect. The defect was then simply opened up and incorporated into our final closure, which was performed with running loop nylon from symphysis pubis to well above the umbilicus. We washed the subcutaneous tissues again and closed the skin with staples.

The patient tolerated the procedure well. Class 3. Sponge and needle counts correct. He received intravenous Cefotan 1 gram intra-operatively.

Dr. Reddy placed an epidural catheter for pain control post-operatively.

Dr. Randy Friesen

cc: Dr. M. Halyk
cc: Dr. L. Lanoie
cc: Saskatoon Cancer Center
Job: 6404