OPERATIVE NOTE:
PREOPERATIVE DIAGNOSIS: Abdominal pain concerning for cecal volvulus.
POSTOPERATIVE DIAGNOSIS: Cecal volvulus.
Operation
- Diagnostic laparoscopy.
- Conversion to open exploratory laparotomy.
- Right hemicolectomy.
Procedure/Description
...We then tried to identify the anatomy. We placed the omentum into the left upper quadrant. We initially started to mobilize the duodenum from some flimsy adhesions to the small bowel. However, we were prevented from fully evaluating the small bowel by a large, dilated cecum within the left upper quadrant. It was very difficult to mobilize and showed signs of ischemia, thus, we decided to convert to open.
We made a midline incision starting above the umbilicus to 5 cm below. This was made with the knife and carried down with electrocautery up to subcutaneous tissues to the fascia. Eventually, we were able to exteriorize the cecum. It was quite a redundant cecum. This appeared to volvulized. We untorsed this with 3 turns and inspected the bowel. With the cecum detorsed and mobilized we were able to visualize the ligament of Treitz at the end of the duodenum in its normal position. This was then ran th small bowel to the terminal ileum Again, this was still very dilated. He did have some lateral cecum and right colon attachments. The rest of the colon was inspected. The cecum was extremely dilated, and there was large lymph nodes present within the colonic mesentery.
We divided the terminal ileum approximately 10 cm from the ileocecal valve using a GIA stapler. We then divided the transervse colon at the level at which the diameter was normal. The right colon was then removed. We then made a side-to-side, functional end-to-end stapled anastomosis of the terminal ileum to the transverse colon. The common enterotomy was then made with a blue load 80 mm Covidien stapler. This appeared to be hemostatic. The common enterotomy was then closed with a running 3-0 PDS suture. The mesenteric defect was then closed with a running 3-0 PDS suture as well....
Findings
Large, redundant cecum. Intraoperative findings consistent with cecal volvulus. The patient did have some lateral colonic attachments as well as identifiable ligament of Treitz, not consistent with malrotation. Right hemicolectomy was performed with a side-to-side, functional end-to-end stapled anastomosis.