second surgery 4 months later

From: toni welsh (twelsh1@hotmail.com)
Mon Oct 16 21:35:45 2000


findings:the patient after the bilateral salpingo-oophorectomy in april, complained of continued pain on right side, intially felt to be secondary to scar tissue and out patient methods of pain control were attempted. three weeks ago we performed an open laparoscopy, which showed extensive intra-abdominal and pelvic adhesions with the transverse colonand small bowel attached down to the bladder and right pelvic sidewalls, as down to the left pelvic sidewall as well.

five months after laparotomy, and month after laparoscopy:

old scar was removed from umbiliocus down to the fascia.using blunt and sharp disection, we we diessected rectus muscle off the fascia an identified the posterior sheath. the sheath was grasped with hemostats and the perioneal and the cavity was entered in atraumatic fashion and no bowel or bladder involved.The peritoneal cavity was entered up around the umbilicus where we knew we had a window as the bowel was attached lower down on the abdominal cavity. We then extended the peritoeal incision superiorly and then laid it down inferiorly to the bladder around the adhesions.

We then lysed the adhesions to the anterior abdoninal wall which included the transverse colon as well as the small bowel. Once this was taken down, we lysed the adhesions to the pelvic sidewalls and placed a turner warwick retractor. Once the retractor was placed we placed the bladder blade and then lysed the adhesions off the bladder, removing the jejum and ileum from the deep pelvic floor as well as right pelvic sidewall and bladder. the patient had a partial omentectomy with a bilateral salpingo-oophorectomy because previous adhesions and the fact that the omentum was seriously attached with her last surgery, but the potion of the residual omentum was attached down to the bladder which had pulled the transverse colon inferiorly.

we detached the remaining potion of the omentum from the transverse colon allowing the transverse colon to be placed back into its original position and no bledding was noted from the areas. we then dissected the remaining portion of the omentum off the bladder and left pelvic sidewall intact and sent this off for pathological identification. we then did extensive adhesiolysis between the loops of small bowel which had interlooped adhesions, running the bowel completely from the upper jejunum, all the way through the ileum. The bowel was completely freed up at this point. The sigmois colon was not severely or densely attached and filmy adhesions were lysed, putting the sigmoid colon back into position. The cecum itself was attached to the right pelvic floor and this was lysed and placed back into its original position. after this complete adhesiolysis was performed and no further adhesons were noted, we irrigated the pelvis well, and noted no bleeding we then placed interceed along the pelvic floor in the hope of preventing further adhesion formation in the future.Procedure was felt to be complete at this point and the upper abdomen was explored and noted to be normal. Then we placed the bowel back into the abdomen and lap and sponge count were correct at this point. Peritoneum was grasped with kelleys and closed using o Vicryl suture down to the mid portion and then we placed Omaxon on the fascia in interrupted fashion, placing a hand into the abdomen to insure that no bowel was injured placing the fascial sutures. The patient was very thin and the fascia layer was very ill defined around the umbiliocus.

Once we were able to close the fascia down to its mid portion of the incision, we then closed the remaining portion of the peritoneum and then closed the remaining portion of the fascia in interrupted fashion. We then irrigated and closed the subcutaneous tissue in one layer using 3-oVicryl suture interrupted and then closed the skin with staples. A pressure dressing was placed and the needle and sponge count were correct times 3. The patient having tolerated procedure well, was taken to recovery room.

I hope this is explaining it to you kath, I typed it out exactly the way it was written.

Hope you do not mind reading this for me, and I am definitely thinking of seeing Dr R&R, if they can help me. The gyn was upset that transverse colon had started to smother the small bowel, when he did the lap in august it faild, they could not even find the bowels, they were so far pulled down. What do you think of this report?

Tank you so much! Toni


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