Preoperative diagnosis: Carcinoid tumor in the small bowel, terminal ileum.
Operation Laparoscopic-assisted right hemicolectomy with primary anastomosis.
Specimen:
Terminal ileum and right colon.
Further resection proximal margin of terminal ileum.
Further resection distal margin of proximal transverse colon.
Findings: The patient had a mass which had a terminal ileum just next to the cecum which was puckered in on the side with no other dense adhesions. This was freed up and our resection made proximally in the small bowel and distally in the transverse colon. This was done laparoscopically and then primary anastomosis was done via a mini laparotomy around the umbilicus.
Her preop labs showed serotonin level elevated at 699. Otherwise a 5-HIAA test was 6.5, which was within the normal range of 2 to 8. In addition patient had a normal chromogranin A level of 50, with the normal reference value being less than 90.
Procedure
...We inserted a 10 mm laparoscope and surveyed the abdomen. There were no obvious liver lesions. There was no specific inflammatory response except for in the right lower quadrant at the terminal ileum where the mass was visualized and had a puckered appearance, drawing mesentery in around it at the end of the terminal ileum/ileocecal valve area.
...This allowed us visualization in the terminal ileum and cecum. The appendix was also seen. This was gently dissected free, taking down the peritoneal lining and lateral peritoneal reflection and being able to free up the terminal ileum, as well as the pelvic side wall and along the white line of Toldt. We took down the omentum at the level of the transverse colon, taking down any adhesions between the colon and freed the colon and its mesentery from the surrounding tissues. We came across the end of the terminal ileum about 10 to 12 cm proximal to where the mass was seen in the terminal ileum using an EndoGIA blue staple load.
We dissected further near the proximal transverse colon, visualizing within the mesentery where we could make a hole in order to accommodate the Endo GI blue staple load. We fired across the colon laparoscopically using a 60 cm EndoGIA blue staple load. We came across the mesentery between these areas laparoscopically using a harmonic scalpel, dividing the mesentery between the small bowel and large bowel mesentery. Once the specimen was freed up completely we decided to do a mini laparotomy in the midline around the umbilicus in order to accomplish primary anastomosis in a safe manner. We made an incision connecting the 2 port sites, dissected down through skin and subcutaneous tissues using Bovie electrocautery to reach the level of the fascia which was incised and continuing the incision through the previous port site up around the umbilicus to the right side for about 4 to 5 cm above the umbilicus. We reached the level of peritoneum and incised through this, given the patient had just been on CO2 for the laparoscopic portion.
We visualized the cut ends of the bowel and removed the specimen. We passed the specimen off to pathology. There was a hard, firm mass encroaching on the ileocecal valve area. No other abnormal areas were seen or palpated. The specimen was not opened and we sent it to pathology whole....