Report from Victoria Hospital
Prince Albert, Saskatchewan, Canada

Date: February 24, 2004
Surgeon: Dr. Friesen
Assistant: Dr. Sharma (Resident)
Anesthetist: Dr. Jurgens
Anesthetic: General

FINDINGS
There were moderately extensive omental adhesions plastered over most of the anterior abdominal wall and also involving small bowel loops. There was no evidence visible, or on palpation of any disease below the umbilicus. Above the umbilicus the omental adhesions made anything other than a partial examination impossible. We could not palpate any portion of the liver for example.

In the pelvis was a firm rather nodular infiltrating tumor. It was fixed. It appeared to be attached to the right pelvic sidewall, in keeping with the previous diagnosis of hydroureter. There was an obviously involved right pelvic lymph node. The urinary bladder was plastered onto the anterior aspect of this tumor quite firmly, and over a moderately large area.

IN SUMMARY
Surgical extirpation of this tumor was deemed to be both a very risky maneuver and a maneuver more likely to cause harm than bring about palliation. The patient's stated aversion to having a colostomy was kept in mind during the procedure, but the very significant likelihood of complications otherwise made the presence of a colostomy quite necessary.

OPERATIVE PROCEDURE
The patient was supine under general endotracheal anesthesia with routine prepping and draping. We opened the old midline incision from just below the umbilicus, extending it downwards. Findings were as described above. A rather tedious adhesiolysis was then carried out, first of all freeing up the omentum from the anterior abdominal wall and then freeing up the bowel loops from the pelvis and each other. Having satisfied ourselves that there was no evidence of small bowel obstruction, we turned our attention to the left colon which was boggy and dilated. It had a rather darkish color, in keeping with the previous diagnosis of melanosis coli and this impression was substantiated when the colostomy was matured later on during the procedure.

A fairly through evaluation was made of the pelvic tumor, in terms of probability of resectability, probability of residual tumor, and the likelihood of injury to urinary bladder and/or the right ureter. Consideration was also given to the presence of significant metastatic disease elsewhere, specifically in the liver and in the right pelvic lymph node.

Weighing all of the above in mind, we elected not to pursue what would have been a very technical aggressive resection and elected to perform a left iliac colostomy.

A button of skin was excised in the left lower quadrant. The subcutaneous tissue was also excised. The anterior rectus sheath was divided transversely and the muscles were split. The posterior rectus was divided longitudinally/vertically. A loop of sigmoid was then brought up through this opening which was wide enough yo admit two fingers. A loop was help in place with Babcock forceps.

We washed and suctioned carefully in the pelvis and lower abdomen. The incision was closed with running loop nylon. We washed and suctioned the subcutaneous tissue. The skin was closed with staples and a water tight dressing was applied.

The colostomy was then opened up using electrocautery. There was a little of oozing and this was stopped with both cautery and manual pressure. A bridge was placed to a small opening in the mesentery adjacent to the bowel. The bridge was rather long and large and we therefore shortened up the wings and used a 2-0 Prolene on a cutting needle to suture the bridge to the skim a bit closer to the actual stoma opening. The appliance was then carefully placed.

The patient tolerated the procedure well. Class II. Sponge and needle counts correct.

Dr. Randy Friesen

cc: Dr. Unsworth
cc: Saskatoon Cancer Centre
Job: 9216