PMC6598601_01
Pre-operative CT images: A) Large phlegmon in LUQ "star" with intra-luminal calcification "arrow". A large right kidney is also noted. B) Note part of the ascending colon "arrow" is running behind the root of mesentery.
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Computed tomography (CT) scanning of the abdomen revealed a phlegmon in the LUQ and free fluid (Fig. 1A). In addition, a large right kidney, an atrophied left kidney, and two ureters were noted (Fig. 1B).
A) Extensive peritoneal disease with carpet-like thick mucoid deposits. B) The D-J junction "black arrow" is right to the midline. The ascending colon "blue arrow" is coming partially behind the root of mesentery and then continues anteriorly as the transverse colon "yellow arrow".
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Exploratory laparotomy revealed extensive deposits all over (Fig. 2A), giving a Peritoneal Cancer Index (PCI) of 39. The duodenum was partially intraperitoneal (Fig. 2B).
The abnormal anatomy of the gut: A) Schematic representation of the malrotation margins of the en-bloc resection delineated with markings "- - - -". The A-D labeling to facilitate follow up on coming figures. B) Another view with the transverse colon elevated upwards to reveal the vascular anatomy. a: artery. Sup: Superior. Rt: Right. Inf: inferior.
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Thus, the resection was extended to include the entire colon beyond the distal transverse with the upper two-thirds of the rectum (Fig. 3A and B).
The improvised technique: A) After the en-bloc resection, the distal end of the transverse colon rotated from left to right and repositioned to reach the low rectum along the right side. B) The rotation of the transverse colon involves the 2700 anti-clockwise rotation around the middle vascular pedicle. a: artery. inf: inferior.
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At this position, the distal end of the transverse colon reached the low rectum without tension through the right side (Fig. 4A and B).
The final anatomy after re-construction: double barrel stoma created with proximal end of the transverse colon and ileum. The rotated end of the transverse colon is anastomosed to the low rectum in the new anatomical position.
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Therefore, we proceeded with the anastomosis by connecting the low rectal stump to the rotated distal transverse colon, using the stapled technique (Fig. 5). The midline laparotomy wound was closed, and a double-barrel stoma was created with the distal ileum as one end, and the proximal part of the remaining colon as the mucous fistula (Fig. 5).
Post operative Barium study. The flowing of contrast through the stoma demonstrates the new anatomy.
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Postoperative abdominal CT scan was performed with barium injected through the stoma, which showed no leak or collection (Fig. 6).