Preoperative Diagnosis: Persistent acute diverticulitis with possible abscess formation

Postoperative Diagnosis: Same, with adhesions

Operation: Exploratory lap, lysis of adhesions, Hartmann's procedure with end colostomy

Procedure: The patient was anesthetized, prepped and draped in the usual manner. Lower midline incision was made which was deviated at the umbilicus to the left and deepened. Bleeders were cauterized. Fascia and peritoneum were incised, and the abdomen entered.

The patient had some reactionary fluid in the pelvic cavity which was aspirated. It was found that a loop of small bowel was fixed to the sigmoid colon, and sigmoid colon was found to form a large mass which was fixed to the lateral abdominal wall. All other areas were checked. Patient had diverticula in the sigmoid colon. Transverse colon, ascending colon, and cecum were normal. The remaining portion of the small bowel was normal. The peritoneum which was adherent to the sigmoid colon was slowly with sharp and blunt dissection separated completely and the small intestine pushed up and retracted. Retractors were applied to the sigmoid colon, which was adherent to the lateral abdominal wall, and this was separated slowly. Once it was separated, the peritoneal fold on the lateral reflection on the outside was incised and slowly cut all the way down to the pelvis. Ureter was checked and was saved, as were the iliac vessels. The site of resection was decided upon, and proximally a small opening was made and a clamp was passed through this and the mesenteric vessels were clamped, cut and tied with 2-0 Vicryl. Slowly in a similar way, the procedure was carried out distally, remaining close to the sigmoid colon, all the way down to the rectosigmoid junction. There was no bleeding, and at the rectosigmoid junction the colon was completely separated from the surrounding tissue and the TA-55 was applied and the staple was fired and the Kocher clamp was applied proximally and was cut in between. The edges were cauterized. No bleeding was found. The remnant of the rectum which was transected was left as it is. Betadine was applied over the transected area and checked proximally. The lateral reflection was cut all the way down to the spleen and the colon was pushed down. The length was obtained and then at the site of resection, stone clamp was passed, and Kocher clamp was passed distal to that and transsection was carried out. Site of colostomy was decided. Skin disk was removed and subcutaneous tissue incised with electrocautery, as was the fascia, and opening was made through the peritoneal cavity. Stone clamp was passed slowly, pulled out with the end of the colon and left out. All areas were irrigated. Peritonealization was carried out with 3-0 Vicryl, and the end of the sigmoid colon which was coming out was fixed to the peritoneum with 2-0 Vicryl running and a few interrupted stitches. The area was thoroughly irrigated.

In the upper part of the abdomen closure was carried out with 0-Vicryl, taking peritoneum and fascia together and a few reinforcing stitches. In the lower part closure was done in two layers. The peritoneal approximation was carried out with 2-0 Vicryl running stitch, and the fascia approximation was carried out with 0 Vicryl running stitch. A few reinforcing stitches were applied. Subcutaneous tissue loosely approximated with 2-0 plain catgut and skin approximated with autosuture stainless steel clips. Betadine dressing applied. Betadine was applied around the end of the sigmoid colon which was left out with the stone clamp. Vaseline dressing applied over that. Patient tolerated the procedure well, transferred to the recovery room in satisfactory condition.