ICD-10: Case Study
PREOPERATIVE DIAGNOSIS: Morbid obesity with significant comorbidities.
POSTOPERATIVE DIAGNOSIS: Morbid obesity with significant comorbidities and BMI of 45.0.
PROCEDURE: Laparoscopic adjustable gastric band with an AP standard band.
ANESTHESIA: General via endotracheal tube.
ESTIMATED BLOOD LOSS: Minimal.
INDICATION: Patient is a very pleasant 33 year-old female who has developed morbid obesity due to excessive calories, who successfully completed all aspects of our multidisciplinary bariatric surgery program. The patient has successfully completed two-week liquid diet and now wishes to proceed with laparoscopic adjustable gastric band.
PROCEDURE IN DETAIL: After consent was obtained, the patient was taken to the operating room. The patient was placed in the supine position, was sedated and was administered general endotracheal anesthesia. The patient was prepped and draped in the usual sterile fashion. After appropriate antibiotics, a time out was accomplished. We made a right mid abdominal incision and a camera trocar was passed into the abdominal cavity under direct vision of the scope. C02 was allowed to insufflate the abdominal cavity to approximately 15 millimeters of Mercury pressure. After appropriate insufflation, the camera was reinserted and a second right upper quadrant incision was created. A left mid abdominal incision was created and left upper quadrant subcostal incision was created and 12-mm, 15-mm and 5-mm trocars were passed respectively. The patient was placed in the steep reverse Trendelenburg. A small incision was created in the subxiphoid space and a Nathanson liver retractor was passed into the abdominal cavity under direct vision of the scope. The left lobe of the liver was retracted appropriately, it was then attached to the Bookwalter and then to the bed for appropriate liver retraction. The angle of His was taken down with the Harmonic scalpel to identify the left crease of the diaphragm. The anterior stomach fat pad was taken off of the stomach with the Harmonic scalpel. We then opened up the pars flaccida, identified the right crus of the diaphragm, made a small incision over the peritoneum and passed the band passer towards the angle of His with the band passer. We calibrated to an AP standard band. The band was passed transabdominally after being prepared on the back table and was passed through the 15- mm trocar site, then around the stomach using the band passer. The calibration tubing was passed transorally via anesthesia. Using a 10 millimeter balloon the balloon was pulled up against the GE junction and we calibrated the band appropriately. The balloon was then deflated and calibration tubing was removed. The band was then attached and sutured the distal stomach to the proximal stomach with Endostitch device using 2-0 silk suture. We used three across the anterior surface of the stomach. We then made a transition stitch along the lesser curvature to prevent slippage of the band. Upon completion of this, we pulled the end of the tubing out the 15 millimeter trocar site. The Nathanson liver retractor was removed under direct vision of the scope. All C02 was allowed to evacuate. The trocars were removed. We created a pocket at the 15 millimeter trocar site where we enlarged the incision and using cautery graded the pocket down to the fascia. The port was then attached to the tubing and sutured the port into the pocket using four 2-0 Prolene sutures. We flushed the port with saline. We then closed all skin incisions with 4-0 Monocryl suture in running subcuticular fashion. Dermabond was applied. 0.5 percent Marcaine with epinephrine was used for local postoperative pain control. The patient tolerated the procedure well. All lap, needle, and sponge counts were correct. Upon completion of the operation the patient was extubated in the Operating Suite and transferred to the Recovery Unit in stable condition.
E66.01 Morbid obesity due to excess calories
Z68.42 Body mass index (BMI) 45.0-49.9, adult