PREOPERATIVE DIAGNOSIS: Fournier’s gangrene.
POSTOPERATIVE DIAGNOSIS: Fournier’s gangrene, gastric foreign bodies.
1. Exploratory laparotomy with gastrotomy and removal of gastric foreign body.
2. Placement of 18-French Moss gastrojejunostomy feeding tube.
3. Diverting end-sigmoid colostomy (Hartmann’s procedure).
INDICATIONS: This is a 33-year-old patient with Fournier’s gangrene who presents today for a diverting colostomy due to wound care and placement of a gastrostomy tube for help with further follow-up feeding. He presents today for exploration. The family understands the risks of bleeding, infection, and postoperative fluid collections and wishes to proceed.
PROCEDURE: The patient was brought to the operating room, placed under general anesthesia, and prepped and draped with Betadine solution. A midline incision was made with a #10 blade and dissection was carried down through subcutaneous tissues using electrocautery. The midline fascia was identified and divided. The posterior sheath and peritoneum were sharply incised, thus allowing entry into the peritoneal cavity. There was some free fluid within the peritoneal cavity but no evidence of any abnormalities. We first identified the stomach and could feel what we felt were some polyps in the stomach. We first placed concentric purse-string sutures along the greater curvature of the stomach, opened up the stomach, and then passed an 18-French Moss gastrojejunostomy tube but were unable to get it down through the pylorus. We could feel these multiple masses in the stomach. We tied the purse-string sutures and inflated the balloon. We then made a small opening in the stomach with electrocautery and retrieved about 20 large what appeared to be vegetable matter and partially digested peppers and pickles. We irrigated with saline and then were able to pass the Moss gastrojejunostomy tube, the distal end, down through the pylorus. We closed the gastrotomy with a running 3-0 Vicryl and an outer layer of 3-0 silk Lembert sutures. We irrigated this area well. We then identified the sigmoid colon, fired a TLC-75 stapler across the sigmoid/ descending colon, and then placed a 3-0 Prolene on the rectal stump. We divided the mesentery between right angle clamps and tied the pedicles with 3-0 silk ties. We had a previously marked stomal opening in the left lower quadrant. We grasped this with a Kocher clamp, made an elliptical incision around this, and then divided the anterior sheath of the rectus in cruciate fashion, divided through the rectus muscles, and then opened the posterior sheath and peritoneum. We brought the colon then through this area. There was good mobility of the colon, and the colon was viable. We then irrigated the abdomen with saline, and, once all sponge and needle counts were correct, we closed the midline fascia with a combination of interrupted 0 Vicryl and running 0 PDS. The skin was closed with skin clips. The staple line was then removed from the colon and the colostomy was matured with 3-0 Vicryl sutures. An appliance was placed. All sponge and needle counts were correct. He tolerated this well.
Prior to leaving the operating room, we took down the dressings of his right leg. There was good granulation tissue, which was pink and viable, and we then re-dressed the wound and sent him back to the surgical critical care unit in critical but stable condition.
PATHOLOGY REPORT LATER INDICATED: Idiopathic gangrene. Numerous undigested vegetable matter.
CPT Codes:
ICD-10 Codes

Similar Posts

Leave a Reply

Your email address will not be published. Required fields are marked *