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Sep 11th, 2015 - Spunch36  

Second Request. Ileostomy/colostomy takedown, excision of enetrocutaneous fistula

Hi fellow coders! I am new to General surgery and am in need of some help. This is my first big case and don't want to screw up. Maybe I am over thinking this. Can someone shed some light on this. Thanks in advanced!

Im thinking: 44640, 44620, 15734-50, 49900

Any thoughts?

Here is the op note:

1. S/P multiple exploratory laparotomies due to perforated sigmoid diverticulitis
2. S/P ileostomy
3. S/P sigmoid colostomy and mucous fistula
4. S/P closure of abd wall with mesh

1. Ileostomy takedown with primary end-to-end anastomosis using side to side functional end-to-end stapled anostomoses with GIA 75 stapler.

2. Colostomy takedown

3. Closure of abd wall hernia @ colostomy site measuring 15X10cm. Primary closure using bilateral mobilization of myofascial flaps of the internal oblique and transversus abdominis muscle via component seperation.

4. Excision of an enterocutaneous fistula to the inferior most portion of the midline incision with exsicion of the fistulous tract and the fascia, subquw tissues, and skin.


We started exploring the abd and the small bowel had to be examined Extensive adhesion were noted in the lowermost portion of the incision. At this point it was detected that there was a fistula arising from the defunctionalized segment of the terminl ileum.

This enterocutaneous fistula was excised and the portion of the terminal ileum where the fascial arose was divided with the GIA stapler. The fistula was excised all the way to the fascia, subq tissue, and the skin. The fistula specimen was passed to pathology. At this point, the small bowel was freed, the ilesotomy was freed from the adb wall and was dropped into the peritoneal cavity. A segment of the ileum was divided in order to reach the point where there is adequate blood supply. At this point, a small bowel continuity was established by performing a side-to-side functional end-to-end stapled enteroenterostomy using GIA stapler. The opening in the small bowel was closed using a 3-0 vicryl stitch and reinforced with interrupted silk. The rent in the mesentery of the ileum was corrected using a running 2-0 vicryl stitch.

Attention was then focused to the descending colon. The patient had a previous sigmoid colectomy. The colostomy was freed from the abdominal wall and dropped into the abd cavity. A large parastomal hernia was noted. The distal stump (hartmann's pouch) was also identified. This was also stuck to the abd wall and there might have been also a fistula between the hartmann's pouch and the abd wall. This portion of the hartmann's pouch was the divided and the specimen was sent to path. The descending colon was divided in half to reach a well vascularized segment. An end-to-end stapled anastomosis using a EEA stapler was performed. This was done in a reverse fashion were by the stapler device was inserted int the proximal and the anvil was placed in the distal end. The anastomosis was completed without any difficulty after it was dilated enough t allow the 25mm stapler. The open end of the descending colon was stapled with GIA stapler. The anastomosis was reinforced with interrupted 3-0 silk sutures. The rent in the mesentery was closed with vicryl running stitch.

At this point, a rigid sigmoidoscopy was performed. The examination was done. There were no intraluminal abnormalities. Air was insuflated into the rectum after clamping the descending colon. The integrity of the of the anastomosis was examined by filling the peritoneal cavity with water and no bubbles were noted from the anastomosis. Air was desufflated. 19 Blake drain placed into the pelvis around the anastomosis.

The attention was then focused to the parastomal hernia in the left lower quadrant. This is a large defect and could not be closed primarily. For this reason, the bilateral myofascial flaps were created by mobilizing both the internal oblique as well as the transverse abdominis fascia and muscle. They were both mobilized in order to allow primary closure of the fascia without any tension. This repair was done after adequate mobilization was performed so that the repair would be done without tension. The fascia was then closed using # 1 interupted figure of 8 suture. The subq tissues was copiously irrigated and the suq tissue above it was approximated with 2-0 vicryl.

Similarly, the ileostomy site defect was closed primarily with sutures. Sub tissue was approximated with 2-0 vicyrl and skin was approximated with staples.

Finally, the abd wall was refreshed, all the previous scar was excised including the portion of the enterocutaneous fistula. Fresh healthy well vascularized edges were encountered, The abd wall was then closed in a single layer using # 1 looped PDS. The subq tissue was irrigated and the skin was approximated with staples.

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