I know this is long but I am very confused on revisions and take downs of colostomy-any help is appreciated thank you
PREOPERATIVE DIAGNOSIS: Colostomy stricture.
POSTOPERATIVE DIAGNOSIS: Colostomy stricture secondary to tight fascial opening and small bowel adhesion at the level of the colostomy.
TITLE OF OPERATION: Sigmoidoscopy followed by colostomy revision with partial left colectomy and completion sigmoidoscopy.
CLASSIFICATION: 4 INDICATIONS FOR PROCEDURE: The patient is a frail elderly 85-year-old woman who had undergone emergency laparotomy for ischemic colitis. She had done well initially but failed to have colostomy output and was having increasing abdominal pain. Abdominal x-rays documented relative obstruction of the level of the fascia with large amount of impacted stool. She was brought to the operating room for exploration of the colostomy.
OPERATIVE FINDINGS: Included an apparent tight fascial opening. I was unable to actually pass a rigid sigmoidoscope through the colon at the level of the fascia. Once the colostomy had been mobilized, it became apparent that not only was the fascial opening somewhat tight but there was a small bowel loop impinged on the colon at the level of the fascia. At the completion of the procedure, the fascial opening was generous and sigmoidoscope passed nicely to 15 cm.
DETAILS OF THE PROCEDURE: The patient was brought to the operating room and placed in supine position. Following IV sedation, she initially underwent sigmoidoscopy through the colostomy. The stoma was gently probed initially with surgeon's finger. There appeared to be a tight fascial opening at this level. Under sedation, attempt was made to advance the sigmoidoscope and we were unable to pass the sigmoidoscope at this point. The patient was then put under general anesthetic by endotracheal tube and she was then prepped and draped in the usual fashion using Betadine scrub and solution. Once this was accomplished, operative area was infiltrated with local anesthetic. The colostomy was mobilized by dividing the retaining sutures and using gentle blunt and sharp dissection, the colostomy was mobilized from the subcutaneous tissue and fascia. Palpation of the abdominal cavity demonstrated multiple omental adhesions. As noted above, the fascia appeared to be quite tight, measured approximately 1 cm, was gently dilated digitally. Additional 1 cm incision was made in the rectus sheath at this level with partial vision of rectus muscle. This allowed for generous opening. The patient's abdominal cavity demonstrated multiple areas of rock-hard stool within the transverse colon. Initial attempts were made to remove these with ring forceps. However, this was unsuccessful. Using gentle digital dissection, the colon was partially disimpacted of stool. Gloves were changed and a Foley catheter was placed at the end of the bowel. It was inflated and 1200 cc of saline was then used to irrigate the colon. Approximately 4 cm proximal to the Foley, there was leakage of the irrigant indicating a tear on the wall of the colon. This was controlled with a right-angle clamp. There was no appreciable spill of stool. I elected to further mobilize the colostomy so that we may resect the colon just proximal to the area of the tear. After irrigation, the colon was mobilized between Kelly clamps and ties. It was divided between Allen clamps and the affected portion was passed off the field. Colostomy was then matured by using multiple sutures of 2-0 Vicryl. Two sutures of 0 silk were first placed to attach the colon to the peritoneum. The colostomy was then matured using multiple sutures of 2-0 Vicryl. At the completion of the procedure, the lumen was widely patent. There was no evidence of a fascial stricture. Appliance was applied and completion sigmoidoscopy actually documented widely patent lumen, no
evidence of mucosal injury and liquid stool within the colon. The patient tolerated the procedure well. The appliance was closed. She was brought back to recovery room in stable condition.