Monday, January 25, 2010

No wonder it took 9 hours

post operative report


ASSISTANT: Carlo Contreras, MD

PREOPERATIVE DIAGNOSIS: Low-grade mucinous adenocarcinoma of the appendix with peritoneal dissemination.

POSTOPERATIVE DIAGNOSIS: Low-grade mucinous adenocarcinoma of the appendix with peritoneal dissemination.

1. Exploratory laparotomy.
2. Lysis of adhesions
3. Complete cytoreduction with the following procedures performed:
a. Omentectomy.
b. Peritonectomy of right upper diaphragmatic surface with resection of
tumor confluence greater than 10cm.
c. Left lower quadrant peritonectomy.
d. Cholecystectomy.
e. Extended right colectomy with an ileotransverse colostomy.
f. Resection of mesenteric nodules.
g. Resection of pelvic nodules.
4. Feeding jejunostomy-tube placement
5. Drainage gastrostomy-tube placement.
6. Right thoracostomy-tube placement.
7. Placement of right subclavian vein central venous catheter.

ANESTHESIA: General endotracheal.

INTRAVENOUS FLUIDS: Crystalloid 2000 cubic centimeters, colloid 3800.

ESTIMATED URINE OUTPUT: 400 cubic centimeters.

ESTIMATED BLOOD LOSS: 270 cubic centimeters.

CHEST TUBE: 400 cubic centimeters.

COMPLICATIONS: None apparent.

1. All peritonectomy specimens were sent together.
2. Cholecystectomy.
3. Right colon.

1. There was no evidence of ascites.
2. There was tumor confluence or acellular mucin over greater than 10 cm over the right diaphragmatic surface.
3. There was tumor confluence on the left pelvic sidewall.
4. There was tumor within the pelvis below the pelvic inlet.
5. There were scattered nodules throughout the small-bowel mesentery.
6. There were small nodules of mucin or tumor in the omentum.
7. A distended gallbladder.
8. I estimate a peritoneal carcinoma index (PCI) of 21.
9. This is a completeness of cytoreduction (CCR) equal to 0.

INDICATIONS FOR SURGERY: Patient is a 41-year-old male with a history of a well-differentiated appendiceal adenocarcinoma with peritoneal dissemination. He was originally seen at an outside institution at which time he underwent an ileal cecectomy in August 2009. This was the origin of his diagnosis. At the time, his surgeon did state that there were still tumor nodules within the small bowel and within the abdomen. Given this, we have recommended that he consider further cytoreductive surgery and possible hypothermic intraperitoneal chemotherapy. He sought second opinions at Pittsburgh, as well as at M. D. Anderson Cancer Center. We agreed and felt that he was a candidate for completion cytoreduction and hypothermic intraperitoneal chemotherapy. At this point, risks, benefits and alternatives were discussed with him at length in the office. He understood all of this and wished to proceed.

PROCEDURE IN DETAIL: The patient was identified in the preoperative holding area, then taken to the operating room and placed on the operating-room table. Once appropriate cardiac and respiratory monitors were attached and the patient had Venodynes placed, he underwent epidural-catheter placement. At that point, the patient was now placed supine on the operating table. He underwent uneventful general endotracheal anesthesia. At that point, a time-out procedure was performed, identifying the patient and that the proper procedure was being performed. Anesthesia attempeted to place a right internal jugular vein catheter but that was not successful. Therefore we turned our attention to placement of a right subclavian vein central line. His right chest and neck were prepped and drapped in the standard surgical fashion. The access needle was advanced under the clavical and the subclavian vein was easily cannulated. The guidewire was advanced and the needle was removed. The dilator was then passed without difficulty. A double lumen catheter was then passed over the wire and the wire was removed. The ports worked well. The line was sutured into place. A sterile dressing was applied.

The patient's abdomen was then prepped and draped in standard surgical fashion. We did use an Ioban to help protect the skin during the hyperthermic intraperitoneal chemotherapy. The patient did receive 1 gram of INVANZ prior to the incision. He also received 5,000 units of heparin prior to the incision as he did have a questionable very small right portal vein thrombosis.

We began our incision from just below the xiphoid process to the pubic symphysis. The incision was carried down through skin into the subcutaneous tissues. Electrocautery was then used to dissect down to the level of the fascia. The fascia was then opened in the midline. He had some adhesions in his right lower quadrant at the site of his previous right colectomy. These were taken down. It took approximately 45 minutes to do this. We then placed a Thompson retractor for excellent exposure of the intraabdominal cavity. We then performed our exploration with the findings as noted above. We then took down the falciform ligament all the way to the liver, clamped this within the liver and transected it with a 2-0 silk tie. This was passed off the table as a specimen.

We then began our cytoreductive procedure in the right upper quadrant. There was a 10 cm area confluence of tumor and/or acellular mucin in this area. We therefore performed a right upper quadrant peritonectomy all the way down to the reflection of the liver and to the hepatic veins. This was removed in total and sent off the field. Hemostasis was noted to be excellent at the conclusion of this. Of note, near the central tendon of the diaphragm, we entered the diaphragm. We did not injure the underlying lung parenchyma. We did place a 2-0 running suture of Prolene to close the defect. At this time, we then turned to our left upper quadrant. There was really no disease whatsoever on the left upper quadrant or over the spleen. We then examined the omentum. We dissected this free from the transverse colon from the hepatic to the splenic flexure, completely freeing this up. We then divided the omentum along the gastroepiploic vessels. We did not include the gastroepiploic artery on the greater curvature of the stomach. This was not involved with tumor. We then opened the lesser sac. There was no disease within this area or on the mesentery of the colon. We then explored the small bowel from the ligament of Treitz all the way to the terminal ileum. There were numerous small nodules noted on the mesentery. These were all completely removed using electrocautery dissection. When we reached the terminal ileum and the remainder of the right colon that remained from the previous ileocecectomy, there was mucin and tumor noted. We did feel that we would require a resection of this area.

At this point, we freed up the right colon from the right pelvic sidewall along the White line of Toldt. There was significant scarring and adhesions in this area, and this was quite difficult. Eventually we were able to carry the dissection up over the hepatic flexure to the middle colic vessels. The colon was taken to the left of the middle colic vessels. This area was divided with a GIA stapler. Likewise, at the terminal ileum, where there was no further evidence of disease, this area was also transected with a GIA stapler. The intervening mesentery was scored and vessels were taken with a series of interrupted 2-0 silk ties or stick-ties and divided. All major vessels had ties and stick-ties placed for security. The colon and terminal ileum were then passed off the table as a specimen. We inspected both ends of the colon and the terminal ileum that had been transected and the blood supply appeared to be excellent.

We then inspected the pelvis. The left pelvic sidewall did have nodules and or mucin on peritoneum, and this was excised with a left lower-quadrant peritonectomy. Deep in the pelvis, on the sigmoid colon, the mesentery had very small nodules, and these were removed without the necessity to resect the sigmoid or rectum.

We then inspected the porta hepatis very carefully. There did not appear to be any disease there. Posterior to the liver, there was an area overlying the kidney, including the triangular ligament of the liver, was identified, and this was resected. The gallbladder appeared quite distended raising concern of possible cholecystectomy in the postoperative period. We felt that it was best to do a cholecystectomy. For this reason, the gallbladder was grasped with a Kelly clamp, and using electrocautery and the Argon-beam coagulator, the gallbladder was resected from the gallbladder fossa. At this point, the cystic artery was identified and was suture ligated. The cystic duct was also identified and ligated and transected. The gallbladder was passed off as a specimen.

An area near his original incision did appear to have some scar or disease and because it was not possible to discern which, this was easily excised and sent off the table as a specimen.

At this point, we felt that we had achieved an optimal cytoreduction and that he was an excellent candidate for peritoneal perfusion. We then placed three temperature probes, one in the left lobe of the liver, one in the ligament of Treitz, and the final one in the sigmoid mesentery of the pelvis. These were sutured into place with 3-0 chromic sutures. We then placed our infusion cannula over the liver and our drainage cannula in the pelvis. The midline incision was closed with a running #1 nylon.

Once the perfusion temperature was between 41 and 42 degrees, and the patient was sufficiently cooled, we began our perfusion with 27 mg of mitomycin C in 6 liters of perfusate. We then continued the perfusion for 90 minutes with vigorous shaking of the abdomen throughout. At the conclusion, we were able to return approximately 4 liters of solution. This was disposed within a proper container.

At this point, we removed the nylon suture which had closed the abdomen. We irrigated the abdomen copiously with several liters of normal saline. We then turned our attention to removing the temperature probes, which was done. We then turned our attention to our anastomosis. We placed our terminal ileum in close approximation to the transverse colon and performed a two-layered hand-sewn anastomosis with an outer layer of 3-0 silk and a inner running layer of 3-0 Maxon. Upon completion, the anastomosis was widely patent.
There was a very large mesenteric defect that we felt was not at risk of incarceration and did not close.

We then turned our attention to placement of our feeding jejunostomy tube. Approximately 30 cm distal to the ligament of Treitz, a pursestring suture was placed in the small bowel. A jejunotomy was made. The jejunal tube was brought through the anterior abdominal wall and advanced into the jejunum distally. The pursestring suture was tied down. Lembert sutures were then placed to perform a Witzel tunnel with 3-0 silk sutures. The small bowel was then tacked to the anterior abdominal wall.

We turned our attention to the gastrostomy tube. The gastrostomy tube was advanced through the abdominal wall. Two 2-0 silk pursestring sutures were placed in the anterior surface of the greater curvature of the stomach, and a gastrotomy was made. The gastrostomy tube was advanced through the pursestrings, and these were tied down. The stomach was then sutured to the anterior abdominal wall. At this point, we then irrigated the abdomen copiously and it aspirated it clear. Hemostasis was excellent.

We turned our attention to the placement of a chest tube prior to closing the abdomen. An incision was made at approximately the fifth intercostal space at the mid axillary line. We entered the pleural space with a hemostat. A 24 French chest tube was advanced posteriorly and superiorly into the pleural cavity and sutured into place. This was placed because of the significant amount of resection we did on the diaphragm. There was almost certainly to be a reactive infusion postoperatively. This was sutured into place with silk suture.

A time-out procedure was then performed for closure. Sponge and instrument counts were noted to be correct at this time. We then closed the abdomen with two 0 Maxon sutures, one started superiorly, one started inferiorly, and tied in the middle. The wound was then irrigated again with normal saline and aspirated clear. The skin was then closed with staples. All tubes were sutured in place with 2-0 nylon sutures.

The sponge, needle and instrument counts were noted to be correct at the end of the case. The patient tolerated the procedure well, was awakened in the operating room, taken to the PACU awake and in good condition.


D: 1/9/2010 9:07:12 AM T: 1/9/2010 11:15:34 AM

Electronically signed by KEITH FOURNIER, MD on 01/14/2010 08:35:14.


Kathleen said...

Thanks to massage school, I knew what a good chunk of that meant. Youch. And to be able to dictate what to me is a matter of life or death with such clarity. I like that they did things copiously.

Anonymous said...


You are indeed a brave soul, my terms of some context, my three back surgeries and my total right hip replacement PALE in comparison to what you have endured. In essence, they are akin to a bad cold when cumulatively stacked up against what you have been

You have my utmost respect, support, and admiration. Continue to hang in there - we are all still praying for your complete recovery and safe return to the land of the frozen tundra! :o)

Allan Mitchler

Joe B said...

I can almost envision this as the script for a viral video in which some reporters query a real football coach but w/ this dictation as the dialogue.... a la the Coors light commercials. :-) For a moment you had me back in anatomy & physiology class 34 years ago in college.... argh! Thanks for sharing the details of what you had to go through & I am just glad it went well & they got it all! Keep working hard at healing, Dan. We miss you and are praying and pulling for you!!

Nancy Engberg said...

Man, I am too chicken to get my tonsils taken out! Thanks for sharing but I gotta say I enjoyed your cajun food reports more - let's hope you are out there dancing, shuckin' oysters and slammin down po' boys soon!!!

Anonymous said...

They remembered to take all the sponges out! Hurray!

Anonymous said...

Awesome... amazing... You're still with us. Surgery is a miracle in itself.