[Expert Solution]: This is an 85-year-old who had been…

This is an 85-year-old who had been previously sccn in the office for a colonic mass. Thc patient underwent colonoscopy with biopsy of a large polypoid lesion in the ascending colon* which was found on pathologic examination to bc adenocarcinoma. Thc patient was originally scheduled to undergo a laparoscopic right colon resection as outpatient. The operation was delaycd due to cardiac issues. While awaiting surgery, the patient developed severe abdominal pain, camc into rhe hospital, was evaluated with CT of the pelvis, was found to have findings consistent with small bowel obstruction. The patient did not appear clinically obstructed. A small bowel followthrough was obtained, which revealed no evidence of obstruction; however, after conferring with the patient and famiy, it appears that patient has been having significant pain and discomfort for some time. Although thc original plan was to send patient home and then to proceed with electivc colectomy as previously recommended, a decision was made just to proceed to the operating room with an open exploratory laparotomy to have a bettc.r understanding of what was happening and procccd with a right colectomy and a possibility of bowel resection (if there was a small-bowel obstruction prescnt) to be performed as well. The indications as well as risks, benefits, potential complications, and alternatives to the opcration were carefully explained to the patient and family on several separate occasions. After all of the questions were answered to the best of my ability, the paticnt decided to proceed with the operation. Consent was obtained, and thc patient was taken to the operating room. Procedure In detail: The patient was taken to the opcrating room, placed in supine position. After sufficient anesthesia had been obtained, the abdomen was prepped and draped in standard surgical fashion, A midline laparotomy incision was made in the usual fashion. The peritoneum abdomcn and the small bowel were identified; it was noted to be normal. There was no evidence of obstruction. There was some dilatation in the terminal ileum, but nothing to suggest that there was an obstruction. (tareful palpation of the ascending colon revealed a large mass. At this point, we decided to proceed with en bloc resection of area. The peritoneum was incised lateral to thc mass and then dissection was carried superiorly, infcriorly, and in the retroperitoneal area, the mass was complctcly mobilized free from surrounding structures. The mass along with the ascending colon was then delivered into the operative field. The colon was transected proximal to the right branch of the middle colic artcry, The small bowei was transected approximately 5 cm proximal to the ilcocccal valve. The mesentery was sequentially ligated and divided using a combination of LigaSure and () silk tics. The mass then passed off the field, submitted to pathology. Thcrc was some oozing from the retroperitoneum, After the specimen was passed off, using a combination of Hemoclips as well as suture ligatures, this bleeding was controlled. It was not active hemorrhage, but rather nuisancc blccding. The area was then thoroughly explored, irrigatcd, and again inspected for hemostasis. T herc was excellent hemostasis. A primary stapled anastomosis was then created between the terminal ileum and the transvecsc colon by using 3.5 GIA stapler and the end was closed by using a TA stapler. “Ifhe staple lines were reinforced by using 3-0 silk sutures. The mesenteric defect was closed by using 3-0 sifk sutures in a figure-ofeight fashion. The retropcritoncal region where the previous bleeding had been localized was thoroughly inspected; there was excc}lcnt hemostasis and the right ureter was identified and notcd to be normal along its course. After the retropcritoncum had been inspected, the bowel was returned to its normal anatomic position. The abdomen was then closcd by using a running #1 looped PDS suture to reapproximatc the fascial layers. There was a small umbilical hernia that was encounte.red. The fascial defect was idcntifcd. The edges were carefully delineated, and the hernia repair was incorporated into the closure. Prior to closure of thc abdomen, the abdomen was irrigated with approximately 3L of warm normal saline. After closure of the abdomen, the subcutaneous tissues were then also thoroughly irrigated wit.h anot.her liter of warm normal saline, A 10 Blakc drain was then placed within the subcutancous tissues, brought through a stab incision in the right tower quadrant. The skin was closed using skin staples. At the completion of the operation, all sponge, needEe, and instrument counts were correct. There were no complications, Prior to closure, a thorough wound exploration was also performed and no laparotomy sponges could be felt within. ICD-10-CM codes: 2 codes ICD-10-PCS codes: 2 codes