Discharge Summary

DISCHARGE DIAGNOSIS: T1NOMO adenocarcinoma of the colon.

PROCEDURES PERFORMED: Laparoscopic right colectomy.

HISTORY OF PRESENT ILLNESS: The patient is a 69 -year -old female, who on ascreen1ng colonoscopy, was found have a friable polyp in the ascending colon .Pathology from the biopsy showed invasive moderately differentiatedadenocarcinoma . She underwent preoperative staging showing no evidence ofmetastatic disease. She thus was consented to go to the operating roomfor a laparoscopic right colectomy.

HOSPITAL COURSE: Mrs. was admitted to the hospital and taken to theoperating room for the above procedure, which was performed withoutcomplication . She was admitted to the surgical floor postoperatively.The day following the surgery, her Foley catheter was removed and she wasmaintained on IV pain medication. Type 2 diabetes was controlled during her stay .He r home medications of metformin andSynthroid were also begun at this time . The following day, she was havingbowel movements as well as passing gas. Her diet was also advanced tosips of clears. She was subsequently advanced to a regular diet,which she tolerated without difficulty . She continued to have good bowelfunction. Her pain control was adequate when she was transitioned to oralpain medication. She was ultimately discharged to home on postoperativeday #4 as she was afebrile with normal and stable vital signs.

DISPOSITION: She was discharged on aregular diet. Her activity is as tolerated limiting heavy lifting to nomore than 15 pounds for 4 weeks. She has a followup appointmentscheduled with Dr. i n 2 -3 weeks. She is to resume her homemedications.

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PREOPERATIVE DIAGNOS IS, Colon cancer .

POSTOPERATIVE DIAGNOSIS, Colon cancer .

OPERATION PERFORMED: La p a r o s c o pic right colectomy.

ANESTHES IA, General.

INDICATIONS: The p a t i ent is a 69-year-old female who underwent a routinescreening colonoscopy and was found to h a v e a fr iable polyp i n t heascending colon that was removed by h o t b iopsy f o r c e p s . Pathology f r omthat polyp showed inv a s i v e moderately- d ifferent iated a denocarcinoma. Sheunde rwent a CT scan o f the abdomen and p elvis wh ich showed n o evidence ofmetastatic d i s e a s e . She had a PET scan wh ich also showed n o evidence ofmetas tat ic d isease. She wi l l now u n d erg o a l aparo s c opic r ight colectomyfor a cancer o f the ascending colon .

OPERATIVE FINDINGS : Th e patient h a d no evidence of metastatic disease, a ndthe l i v e r a nd s ma l l bowel were grossly normal. Th e r e were n o susp~c~ous

enlarged l ymph n o d e s either. Upon open i ng t he specimen after removal, a 1cm f irm mass was pre s e n t in the p roxima l ascend ing colon 5 cm distal t othe i leocecal valve. The patient ' s h e p a ti c fl exur e was moderate lyredundant.

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PROCEDURE I N DETAI L : After informed c o n s e n t was o b t a i ned, the pat i ent wasbrought t o t he ope r a t i n g r o om a n d pla c e d i n the supine position on theop e r a t i n g room tab le. Sequen t i a l compression devic es we r e pla c ed on thel ower extr e mi t i e s pri or t o i nd uc tion, and general a nes t hes ia wa s i n ducedwithout diffi c u l t y . A Fole y cat he ter wa s inser ted . A b e anbag was u sed onthe operatin g r o om table t o prevent h e r from sliding o f f the t ab l e i nste ep Trende l e n burg position . Her abdomen wa s sterilely prepped and d r apedi n the usu a l fashion.

A 1 e m supr a umbilical v ertical incision wa s ma de in the skin with a # 1 1blade after i n s tillation o f 0 .5 % Marcaine i n the skin and subcut a n e oustissue. Th e a b domi nal wa l l was e lev ated with t o wel c l a mp s, a n d a Ve r es sneedle was inserted i n to the abdomina l cavity. Af ter a positive salinedrop test , the abdomen was insufflated with C02 gas t o a p r essure of 15.The Veress need le was removed, a n d a 12 -mm b ladeles s tro c ar was i ns e r t edthrough the supraumbi l i c a l incision . A 10 -mm 30 - deg ree laparosc ope wasinserted t h rough the supraumbilical port, and the abdomen was e xplored.The op era tive findings are noted a bove. The liver was inspe cted r eve a l ingn o evidenc e o f metas t a t ic di s e a s e .

Thre e addi t i o n a l b lade less trocars were inser ted into the a bdominal cavi t yunder dire c t o b serva t ion after insti l l at i on o f 0 . 5% Marc aine in theabdominal wa l l . A 5 mm tro car wa s pla c e d on the l eft side of the a b domen 2fingerbreadth s med ial and s upe r ior to t h e l ef t sup e rior ilia c crest. A5 -mm troc a r wa s placed in the l eft upper q uadrant 4 fingerbreadths a bovethe l eft l ower q uadrant p ort . Finally , a 5 mm tro car was pla c ed on ther i g h t side o f the abdomen just a bove the l e v el o f the umbilicus 2fingerbrea dths med ial t o the right s u perior ilia c c res t .

The cecum was g r a sped wi t h a n a t raumatic b owel grasper and e levated towardthe anteri or abdominal wa l l , e xpos i n g t h e o r i g i n o f the ile o col i c v esselson stretch . A window was c re a ted infer i orly and p osteriorly t o theile o c olic v e s s e l s u sing cau te ry Endo s h e a r s , and t he u nde rside o f the r igh tcolon was d i s s e c t ed fr e e from the re troperi toneu m using blunt d i s s e ct i on .The disse c t i o n proce eded underne ath the mesen tery o f the colon cau dallyalong the righ t paracol ic gutter t oward the h epatic fl exure . The du ode numwas carefu l l y iden t i f ied a n d preserv ed. The ile o colic v essels we r e d i v idedat their base us i n g the Li gaSure dev i c e wi th a quadruple- seal tec h n i que .Hemostasis wa s evi dent .

Disse ction cont inued underneath the me s ent ery o f the colon up t o the

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duodenum whi ch wa s identi fi ed and preserved as a bove . The r etrope ritone alstructures were bluntly dissec ted inferiorly a way from the overlyingmesentery . The c ecum and right colon were t hen re f lected medially , and a n yremaining lateral peri t oneal attachments were t ake n down using hook Bov i ee lec t r oca u te r y . The h epatic f l exure was comp l ete ly taken d own a ndmobilized using hook Bov ie e lec t r o c a u te r y . The omen t u m was removed fromthe p r oxima l transverse colon up to t h e falc iform ligament . Havingc omp le t e ly mobi l ized the entire right c olon, preparation was made for theopen part o f the pro c edure .

The supraumbil ical po r t was used to o pen a 4 -cm supraumbilical verticalincision. A smal l Al e xis wound r etractor was i nserted into the incision .The terminal ileum and right colon were de livered into the wound witho u tdiffi culty. There was no ten s i o n on t he mesent ery . The t erminal ileum wa sdiv i d e d a p prox i mat e ly 15 em p r o x i ma l to t h e i leocecal valve using a GIA 8 0mm staple r. The te rmi nal i l ea l mesente ry was tak e n d own and dividedradially using the Li gaSu r e device . The t r ansve r s e colon distal to theright branch o f t he mi d d le colic art ery was divided u sing a GIA 80 mmstapler. The int erv e ning c o l o n ic mesent ery dista l to the divided ileoc o l i cv essels was taken d own a n d divided using the Liga Sure device whichincluded the righ t bra n ch of t h e middl e colic a rt e r y . The specimen wasr emoved from the o perat ive fie ld and submi t t ed f o r pathological analys is .The spe cimen was opened on t h e back t a b l e r evealing the above operativefindings.

The terminal ileum and d i vided t ransve rse co l on were b r ou g h t into c l o s eproximity for a side - t o -side anastomosis . Care ful attention was made thatthe t erminal ile um was not twisted prior to t he anastomosis . The 2 c o rnersof e a c h stapl e l ine of t he t erminal il eum and t r a n s e c ted transverse c o l o nwere e x c i sed using a curved Mayo scissors, a nd a sid e -to -side functionale n d - t o -en d anas t omosis was const ructed using a single fi re of the GIA 80mm stapler . The 2 s u t u res of 3 -0 Vicryl were p laced at the c r o t c h of thestaple line to avoid tens i o n . The s tapl e h o l e was t hen closed us ing aTX60B l i nea r stapl er a nd the stapl e line was ov e r sewn and inverted us i nginterrupted 3 -0 Vicryl Le mbe r t sutures . Bo t h the t e r mi n a l ileum and c o l onwere p i n k and viabl e wi th e xcellent blood supply a t the anastomosis . Therewas no t ension . The mesen t e r i c defect left by t he r esection was closedusing a running 3 - 0 PDS suture t a k i n g care to preserve the blood supply onboth sides .

The small bowel a nd the anastomosis were re turned to the a bdominal cavi ty,

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and the abdomen was irrigated with a copious amount of saline solution.The abdomen was inspected for hemostasis which was adequate. The remainingomentum was brought down over the small bowel and the anastomosis prior toclosure. The Alexis wound retractor was removed .

The fascia of the small supraumbilical vertical midline incision was closedusing a a-looped PDS suture from either end. All wounds were irrigatedwith saline solution, and the skin of the midline incision was closedusing a running 4 -0 Monocryl subcuticular suture. The skin of the otherport sites was closed using buried interrupted subdermal 4-0 Monocrylsutures. Steri-Strips and sterile Tegaderm dressings were applied.

The patient tolerated the procedure well without complications. Estimatedblood loss was 150 mL. I was present and scrubbed for the entire durationof the operation. The patient was extubated in the operating room andbrought to the recovery room in stable condition.

Active Inpatient Medicntions:cncxeperin 30mg = O.3mL SQ BIDinsulin regular (insul in regular sliding scale) SQ Q6HrAdive PUN Mctli\:utious:HYDROmorphone (HYDROmorphone peA 0.2 mglmL) 0.2tng = ImL IV

As DirectedHYDROmorphone (HYDROmorphone peA BOLUS) 0.4mg = 2mL IV Q2Hrdextrose 50% in water (D50W) 25mL IV As Directednnlmtone (Narcnn) 0.1m = O.25mL IV As Directed

Lnbs: Results shown lire f=o'::, :::,1>".:::".:=.":,3"0"1>::".::"::,,::::::::::- - - - - - - - - --1_ 0641 Red Cell Dlstrlbuti 1·4.4 H

Anion Gnp 6 L Sodium 137Urea Nitrogen 15 WBC 8.93Calcium, Serum or 8A Glucose Level 221 HChloride 107 _ 0500

C02 24 POC G1UOO50 327Creatinine, Serum 0.83 Blood Glucose Tes RoutineHemerocrf 31.1 L Blood Glucose Stic Finger. RightHemoglobi n g/dL 10.4 L _ 2300Mean Corpuscular 30.3 POC Glucose 272Mean Corpuscular 33.5 Blood Glucose. Tes RoutineMC<1n Corpuscular 90.2 Blood Glucose. Stic Finger, LeftMean Platelet Volu 8.6 09103 1800

Platelets 155 L POC Glucose 252Potaeaium 4.5 Blood Glucose Tes RoutineRed Blood Cell Co 3.45 L Blood Glucose Stic Finger

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