1. Abdominal-pelvic mass.
2. Bowel obstruction.
3. Prior hysterectomy.
4. Ovarian mass, suspected primary
malignancy.
5. Abdominal abscess.
6. Right ureteral obstruction.
POSTOPERATIVE
DIAGNOSIS:
1. Abdominal-pelvic mass.
2. Bowel obstruction.
3. Prior hysterectomy.
4. Ovarian mass, suspected primary
malignancy.
5. Abdominal abscess.
6. Right ureteral obstruction.
7. Tumor extension to the small
bowel, large bowel mesentry, pelvic brim.
8. Tumor extension to the stomach.
PROCEDURE:
1.
Exploratory laparotomy with radical pelvic and abdominal tumor debulking
for primary ovarian malignancy including right salpingo-oophorectomy,
retroperitoneal lymphadenectomy, tumor resection from cul-de-sac.
2.
Gastrectomy, partial for tumor extension.
3.
Ileal small bowel resection for obstruction.
4.
Ascending colectomy for tumor mass.
5.
Appendectomy, indicative for tumor nodules.
6.
Mobilization of the splenic and hepatic flexures with ileoascending
colon anastomosis.
7. Right
ureterolysis.
8.
Cystourethroscopy.
9.
Bilateral pelvic drain placement.
10.
Transfusion, 2 units of PRBCs.
11.
Central venous line placement.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 500 mL.
DRAINS: Transurethral
Foley to gravity.
FLUIDS: IV lactated Ringers 2500 mL. IV PRBCs 2 units.
URINE
OUTPUT: 300 mL.
SPECIMENS: Pelvic and cul-de-sac tumor, right ovarian
mass, right fallopian tube inclusive of retroperitoneal lymphadenectomy
specimens, nodal tissue with tumor extension.
Ileocecal mass with distal ileum, small bowel resection, cecum, and
ascending colon. Appendix replaced with
tumor. Infracolic omentectomy specimen.
Partial gastrectomy specimen with tumor mass. Right pelvic sidewall peritoneum with miliary
disease.
CYTOLOGY: Abdominal
ascites.
FINDINGS:
1. Exam under anesthesia: External genitalia/BUS notable for mass
filling the pelvis, extending to the pelvic brim. Limited mobility compatible with fixated
ovarian tumor. Rectal vault with
extrinsic compression without apparent rectal mucosal tumor extension.
2. Operative:
At laparotomy, mass arising from the right pelvic sidewall encasing the
rectosigmoid colon with extension to the ileocecum mesentery, replacement of
suspected appendix with tumor extending to the mesentery at the level of the
pelvic brim. Near-complete obstruction,
ileocecal region, large and small bowel loops with complex mass
encasement. Tumor extension to the
greater curvature of the stomach and greater omentum. Diaphragmatic surfaces are clear. Liver, otherwise, free of parenchymal
pathology on palpation.
3. Pathology.
Evaluation of surgical specimens compatible with primary ovarian
malignancy, pending final review.
DISPOSITION: The patient was transferred to the recovery
room in stable condition.
JUSTIFICATION: The patient is an
83-year-old female admitted for further evaluation and management of above
diagnoses. Prior clinical history
remarkable for worsening abdominal and pelvic pain, nausea, vomiting, and
obstructive-type symptoms. The patient
was admitted and taken to the surgery for the above procedures, for the above
diagnoses. The patient is aware of the potential for thromboembolic
events including deep venous thrombosis, stroke, and pulmonary embolus. She is aware that her risks may be elevated
given her prior medical history, possible diagnosis of suspected malignancy,
anticipated surgical procedures. All of
the patient's questions have been answered, apparently to her
satisfaction. The patient has elected to
proceed with surgery and is medically cleared.
PROCEDURE IN DETAIL: Following documentation of informed consent
for the above procedures, the patient was brought to the operative suite where
she was administered general anesthesia, prepped and draped in the usual
sterile fashion in the low lithotomy position in Allen stirrups. Exam under anesthesia was performed. The above findings were noted. A midline skin incision was made two
fingerbreadths above the symphysis pubis to the level of the umbilicus. Incision was further extended above the
umbilicus with abdominal and pelvic contents noted, suspected infiltrated tumor
involving the omentum, metastatic disease, throughout the abdominal cavity. The incision was further developed, the
abdomen was entered and evacuated with approximately 3 liters of fluid and
ascites, and a thorough and systematic exploration of the abdomen and pelvis
was conducted. The Bookwalter retractor
was placed. The mass arising from the
omentum was mobilized, reflected caudad.
Infracolic omentectomy was carried out taking care to isolate, divide
and ligate all vascular pedicles using 2-0 silk ligatures, and the LigaSure was
also utilized to secure small vessels and lymph channels. Dissection was carried into the splenic and
hepatic flexures. The splenic flexures
were mobilized along the avascular line of Toldt bilaterally. This was done to facilitate mobilization of
the tumor arising from the greater curvature of the stomach. The short gastric vessels are taken down and
gastroepiploic blood supply to the tumor was mobilized and secured using suture
ligatures of 2-0 Vicryl used throughout this case unless otherwise
specified. Ongoing tumor resection from
the greater curvature of the stomach was completed resecting superficial
muscularis en bloc with the tumor. The
resection site was closed using primary layer of 0 Vicryl followed by a
secondary layer of imbricating 2-0 silk suture to reinforce the suture line
with exact hemostasis noted. The area
was irrigated and attention was turned to the pelvis.
Tumor arising from the right pelvic sidewall,
right ovary and tube was noted. The
round ligament on the right side was isolated, divided, and the pararectal and
paravesical spaces are thoroughly developed with identification of the ureters
and major vessels in their pelvic
course bilaterally. The
infundibulopelvic ligament on the right side was isolated, clamped, divided and
doubly ligated using 2-0 silk ligatures.
Right ureterolysis was carried out from the level of the pelvic brim to
level of the uterine vessel remnants which are noted to supply the mass with
significant blood supply from the right hemipelvis. Ongoing en bloc resection was carried out in
a lateral-to-medial direction mobilizing the tumor in a blunt and sharp
dissection taking care to isolate, divide, and ligate all vascular pedicles
using 2-0 silk ligatures. Care was taken
to resect nodal tissue from the length of the external iliac artery and vein
with isolation and preservation of the obturator neurovascular bundle and vital
structures, vessels. Following resection
of the mass to the level of the cul-de-sac, en bloc resection of the peritoneum
was carried out in a lateral-to-medial direction to the level of the rectosigmoid
colon, vaginal cuff apex. The denuded
areas are oversewn using 2-0 Vicryl sutures again with hemostasis noted and the
mass was reflected from the operative field and sent to Pathology. Peritoneum was also resected and sent as
well. The area was irrigated, and
attention was turned to the right hemipelvis, pelvic brim region.
The cecum was mobilized in a
lateral-to-medial direction. The area
distal to the tumor obstruction at the ileocecal valve and mesentery was
mobilized. A window was developed in the
ascending colon where the colon was divided with the aid of the GIA
stapler. Proximal to the area of
obstruction, the small bowel is mobilized and a window developed in the
mesentery. The small bowel was divided
at this location as well. The mesentery
was Kocherized and tumor resected en bloc from the mesentery with dissection
carried out again in a lateral-to-medial direction taking care to isolate and
preserve blood supply to the remaining small bowel and large bowel. Mass arising from suspected appendiceal area
was also reflected from the infundibulopelvic ligament region taking care to
isolate and preserve the integrity of the IP pedicle, which was noted to be
hemostatic and secure.
Following resection
of the mesentery, the mass was released en bloc inclusive of the cecum, proximal
ascending colon, distal ileum, and suspected appendix with tumor
replacement. The mass was sent to
pathology. The area was irrigated. The second segment of distal ileum was
resected for mesenteric tumor to assure clean margin. The ascending colon and distal ileal limbs
were all aligned for anastomosis using 3-0 silk ligatures. The GIA was used to create a side-to-side
anastomosis followed by visual inspection of the anastomotic line notable for
integrity, hemostasis. The anastomosis
was completed using the TA 65 stapler and the mesenteric window was closed
using interrupted sutures of 2-0 Vicryl.
The abdomen and pelvis were densely irrigated. Hemostasis noted at all pedicles. Cystourethroscopy was performed. Findings are notable for free spill of indigo carmine dye from both
the right and left ureteral orifice. The
bladder mucosa and the urethral mucosa were free of gross suture violation,
free of evidence of injury or gross pathology.
All instruments were removed from the bladder. A Foley catheter was replaced in the
bladder. The abdomen was then closed
using #1 loop PDS suture to reapproximate the fascial margins in a mass closure
fashion over bilateral pelvic drains.
Subcutaneous tissue irrigated with a bulb syringe and skin margins were
closed with staples. All sponge and
needle counts were correct x3 at the end of the case. The patient tolerated these procedures well
and was transferred to the recovery room in stable condition.
No comments:
Post a Comment