natalieworkman@att.net
Contributor
DATE: 04/24/2020
PREOPERATIVE DIAGNOSES:
1. Anastomotic stricture versus adhesive partial small bowel
obstruction.
2. History of necrotizing enterocolitis with perforation requiring
short-segment small-bowel resection and stoma.
3. Status post ileostomy takedown.
4. History of prematurity, 23 weeks' gestation.
5. Chronic lung disease.
6. Feeding dysfunction.
7. Weight less than 4 kg.
POSTOPERATIVE DIAGNOSES:
1. Partial bowel obstruction secondary to adhesions versus
functional obstruction secondary to segmental intestinal
dysmotility.
2. History of necrotizing enterocolitis with perforation requiring
short-segment small-bowel resection and stoma.
3. Status post ileostomy takedown.
4. History of prematurity, 23 weeks' gestation.
5. Chronic lung disease.
6. Feeding dysfunction.
7. Weight less than 4 kg.
PROCEDURES PERFORMED:
1. Exploratory laparotomy.
2. Extensive enterolysis requiring 40% of the total operative time.
3. Tapering enteroplasty of distal 20 cm of small bowel proximal to
the anastomosis.
4. Stamm gastrostomy button (12-French 1.0 cm MIC-KEY button).
SURGEON:
ANESTHESIA:
General endotracheal anesthesia.
ESTIMATED BLOOD LOSS:
10 mL.
COMPLICATIONS:
None immediately noted.
FINDINGS:
Extensive adhesions throughout the abdomen required 40% of the total
operative time to adequately lyse. Upon evaluation of the
anastomosis in the right upper quadrant, there was no evidence for
stricture. Intestinal contents moved freely from the distal small
bowel into the colon. The distal 22 cm of the ileum proximal to the
anastomosis was dilated. Of note, the remainder of the small bowel
was of normal caliber. Given the concern for this focal dilation,
which was at least twice the size of the remainder of the small
bowel, there was concern for a segmental area of dysfunction
resulting in dilation and poor motility. There was 60 cm proximal to
this area (a total of approximately 90 cm of small bowel), which was
of normal caliber. Given the segmental dilation of this area and a
widely patent anastomosis, I elected to perform tapering enteroplasty
with serial staple fires from the GIA stapler. A 12-French 1.0 cm
MIC-KEY button was placed via the Stamm gastrostomy technique.
SPECIMENS:
Ileum.
INDICATIONS FOR PROCEDURE:
is a now 5-month-old former 23-week gestation infant, who has
had an extensive NICU hospitalization with multiple complications of
prematurity. She required laparotomy early in life for perforated
necrotizing enterocolitis. She subsequently underwent ileostomy
takedown approximately 5 weeks ago. More recently, in the last week,
she has had abdominal distention, dilated segments of intestine on
her plain films and decreased stooling. A barium enema obtained
yesterday revealed findings concerning for a stricture with a colon
of normal diameter and small-bowel dilation proximal to the area of
presumed anastomosis. For this reason, I recommended operative
exploration with revision of the anastomosis. An additional concern
was potential for partial small-bowel obstruction secondary to
adhesions. Additionally, the patient has had feeding dysfunction
always been fed by an NG tube. For this reason, I have been asked
also to place a gastrostomy button at the time of exploration.
Preoperatively, the risks, benefits, and alternatives of this
procedure were discussed with the patient's parents. They stated
understanding and agreed to proceed.
DESCRIPTION OF PROCEDURE:
was taken to the operating room by the ICU and anesthesia
staff. The general anesthesia was then induced. Dr. of
Pediatric Otolaryngology then proceeded with an airway evaluation.
Please see his operative note for specifics of this procedure. I
then encountered the patient in the operating room in the supine
position following the completion of his procedure. Additional IV
access was placed by Anesthesia as well as an arterial line. I then
proceeded to prep and drape the abdomen in usual sterile fashion. A
time-out took place. The patient is already on broad-spectrum
antibiotics given the necrotizing enterocolitis episode last week.
We then proceeded to open the prior transverse abdominal incision.
This was done sharply. Electrocautery was used to carry this down
through subcutaneous tissues. The abdomen was then entered
atraumatically. We then spent a considerable amount of time, 40% of
the total operative time, lysing thin adhesions throughout the
abdomen. Once the adhesions were completely lysed, we evaluated the
bowel from the ligament of Treitz distally to the colon. There were
no evidence for strictures of the small bowel. The bowel did sit in
normal rotational pattern. The proximal 60 cm of small bowel from
the ligament of Treitz onward was of normal caliber and appearance.
There were no areas of ischemia. The last approximately 22 cm of
small bowel was dilated to twice the size of the remainder of the
small bowel. This was before the anastomosis. The anastomosis was
widely patent. I was able to both palpate the anastomosis which felt
wide as well as clearly milk intestinal contents through the anastomosis from
proximal to distal without obstruction. The colon was then
evaluated, appeared to be normal distal to this area. Given this
finding, I was unable to find a stricture to be the source of the
feeding dysfunction and abdominal distention. At that point, it was
assumed that adhesions may be responsible for the partial small-bowel
obstruction. However, additional evaluation of this bowel,
particularly the last 22 cm of small bowel, raises concern for a
relatively dysfunctional intestine due to the significant dilation in
this segment. I had one of my partners, Dr. Alan Ladd, also
visually inspect the intenstine. The question that I
considered was resection of 20 cm of small bowel with repeat
anastomosis to the colon versus tapering enteroplasty. Ultimately, there was
some, ineffectual, but present, peristalsis of that 20 cm and
therefore I elected to perform a tapering enteroplasty. In order to
perform this enteroplasty, I fired serial GIA blue load staple firings
from the proximal area of dilation to near the anastomosis. This was
done in a manner to prevent excess narrowing of the bowel over the length of
this dilation. All of the stapling occurred on the antimesenteric
border. Once this was complete, a specimen called ileum
was passed off the field. We then placed interrupted 4-0 Vicryl
sutures over the corners of the staple firings. Intestinal
contents easily milked through the area without obstruction.
We then copiously irrigated the abdomen. There was a small
bleeding area on the liver capsule in the right upper
quadrant, which was cauterized and provided excellent hemostasis.
The intestine was then placed back in the usual configuration into the
abdomen.
We then proceeded with Stamm gastrostomy. A portion of the stomach
on the greater curvature away from the pylorus was selected for the
gastrostomy site. We measured the abdominal wall and selected a 12-
French 1.0 cm MIC-KEY button as an appropriate size for this patient.
We then placed a stay suture in the stomach in the location of the
gastrostomy button placement. A 4-0 Vicryl was then used to create a pursestring
type suture. Three additional serosa to abdominal wall sutures were
placed. We then made a small gastrotomy. An appropriate position in
the abdominal wall was identified and opened and a hemostat was
placed through this area. We then placed the button through the
abdominal wall into the gastrotomy and blew up the balloon with 3 mL
of sterile water. The pursestring suture followed by the abdominal
wall sutures were then tied down. A final 4-0 Vicryl serosa to
abdominal wall suture was then placed inferiorly. The balloon of the
button sat in appropriate position of the stomach based on palpation.
We then again copiously irrigated the abdomen. Seen excellent
hemostasis. We proceeded to closure. It should be noted that a
short-segment skin flap was made circumferentially around the
incision. This did involve lifting the umbilicus off the fascia in
order to create a good fascial closure. We took care to prevent the
skin flap in the gastrostomy site from connecting. A 3-0 running PDS
sutures were then used to close the abdomen. The umbilicus was then
tacked back down to the fascia to create a neoumbilicus. Marcaine
was placed throughout the operative field (0.25% Marcaine plus
epinephrine diluted half). A running 5-0 subcuticular suture was
then placed. Mastisol and Steri-Strips were then placed. The
dressing was placed on the G-tube site. This concluded the
operation. The patient tolerated this procedure well. All needle,
sponge, and instrument counts were reported as correct at the end of
the procedure. I was present for and performed the entire operation.
The patient was taken back to the NICU intubated in stable condition.
I updated the patient's family as to the outcomes of the surgery
PREOPERATIVE DIAGNOSES:
1. Anastomotic stricture versus adhesive partial small bowel
obstruction.
2. History of necrotizing enterocolitis with perforation requiring
short-segment small-bowel resection and stoma.
3. Status post ileostomy takedown.
4. History of prematurity, 23 weeks' gestation.
5. Chronic lung disease.
6. Feeding dysfunction.
7. Weight less than 4 kg.
POSTOPERATIVE DIAGNOSES:
1. Partial bowel obstruction secondary to adhesions versus
functional obstruction secondary to segmental intestinal
dysmotility.
2. History of necrotizing enterocolitis with perforation requiring
short-segment small-bowel resection and stoma.
3. Status post ileostomy takedown.
4. History of prematurity, 23 weeks' gestation.
5. Chronic lung disease.
6. Feeding dysfunction.
7. Weight less than 4 kg.
PROCEDURES PERFORMED:
1. Exploratory laparotomy.
2. Extensive enterolysis requiring 40% of the total operative time.
3. Tapering enteroplasty of distal 20 cm of small bowel proximal to
the anastomosis.
4. Stamm gastrostomy button (12-French 1.0 cm MIC-KEY button).
SURGEON:
ANESTHESIA:
General endotracheal anesthesia.
ESTIMATED BLOOD LOSS:
10 mL.
COMPLICATIONS:
None immediately noted.
FINDINGS:
Extensive adhesions throughout the abdomen required 40% of the total
operative time to adequately lyse. Upon evaluation of the
anastomosis in the right upper quadrant, there was no evidence for
stricture. Intestinal contents moved freely from the distal small
bowel into the colon. The distal 22 cm of the ileum proximal to the
anastomosis was dilated. Of note, the remainder of the small bowel
was of normal caliber. Given the concern for this focal dilation,
which was at least twice the size of the remainder of the small
bowel, there was concern for a segmental area of dysfunction
resulting in dilation and poor motility. There was 60 cm proximal to
this area (a total of approximately 90 cm of small bowel), which was
of normal caliber. Given the segmental dilation of this area and a
widely patent anastomosis, I elected to perform tapering enteroplasty
with serial staple fires from the GIA stapler. A 12-French 1.0 cm
MIC-KEY button was placed via the Stamm gastrostomy technique.
SPECIMENS:
Ileum.
INDICATIONS FOR PROCEDURE:
is a now 5-month-old former 23-week gestation infant, who has
had an extensive NICU hospitalization with multiple complications of
prematurity. She required laparotomy early in life for perforated
necrotizing enterocolitis. She subsequently underwent ileostomy
takedown approximately 5 weeks ago. More recently, in the last week,
she has had abdominal distention, dilated segments of intestine on
her plain films and decreased stooling. A barium enema obtained
yesterday revealed findings concerning for a stricture with a colon
of normal diameter and small-bowel dilation proximal to the area of
presumed anastomosis. For this reason, I recommended operative
exploration with revision of the anastomosis. An additional concern
was potential for partial small-bowel obstruction secondary to
adhesions. Additionally, the patient has had feeding dysfunction
always been fed by an NG tube. For this reason, I have been asked
also to place a gastrostomy button at the time of exploration.
Preoperatively, the risks, benefits, and alternatives of this
procedure were discussed with the patient's parents. They stated
understanding and agreed to proceed.
DESCRIPTION OF PROCEDURE:
was taken to the operating room by the ICU and anesthesia
staff. The general anesthesia was then induced. Dr. of
Pediatric Otolaryngology then proceeded with an airway evaluation.
Please see his operative note for specifics of this procedure. I
then encountered the patient in the operating room in the supine
position following the completion of his procedure. Additional IV
access was placed by Anesthesia as well as an arterial line. I then
proceeded to prep and drape the abdomen in usual sterile fashion. A
time-out took place. The patient is already on broad-spectrum
antibiotics given the necrotizing enterocolitis episode last week.
We then proceeded to open the prior transverse abdominal incision.
This was done sharply. Electrocautery was used to carry this down
through subcutaneous tissues. The abdomen was then entered
atraumatically. We then spent a considerable amount of time, 40% of
the total operative time, lysing thin adhesions throughout the
abdomen. Once the adhesions were completely lysed, we evaluated the
bowel from the ligament of Treitz distally to the colon. There were
no evidence for strictures of the small bowel. The bowel did sit in
normal rotational pattern. The proximal 60 cm of small bowel from
the ligament of Treitz onward was of normal caliber and appearance.
There were no areas of ischemia. The last approximately 22 cm of
small bowel was dilated to twice the size of the remainder of the
small bowel. This was before the anastomosis. The anastomosis was
widely patent. I was able to both palpate the anastomosis which felt
wide as well as clearly milk intestinal contents through the anastomosis from
proximal to distal without obstruction. The colon was then
evaluated, appeared to be normal distal to this area. Given this
finding, I was unable to find a stricture to be the source of the
feeding dysfunction and abdominal distention. At that point, it was
assumed that adhesions may be responsible for the partial small-bowel
obstruction. However, additional evaluation of this bowel,
particularly the last 22 cm of small bowel, raises concern for a
relatively dysfunctional intestine due to the significant dilation in
this segment. I had one of my partners, Dr. Alan Ladd, also
visually inspect the intenstine. The question that I
considered was resection of 20 cm of small bowel with repeat
anastomosis to the colon versus tapering enteroplasty. Ultimately, there was
some, ineffectual, but present, peristalsis of that 20 cm and
therefore I elected to perform a tapering enteroplasty. In order to
perform this enteroplasty, I fired serial GIA blue load staple firings
from the proximal area of dilation to near the anastomosis. This was
done in a manner to prevent excess narrowing of the bowel over the length of
this dilation. All of the stapling occurred on the antimesenteric
border. Once this was complete, a specimen called ileum
was passed off the field. We then placed interrupted 4-0 Vicryl
sutures over the corners of the staple firings. Intestinal
contents easily milked through the area without obstruction.
We then copiously irrigated the abdomen. There was a small
bleeding area on the liver capsule in the right upper
quadrant, which was cauterized and provided excellent hemostasis.
The intestine was then placed back in the usual configuration into the
abdomen.
We then proceeded with Stamm gastrostomy. A portion of the stomach
on the greater curvature away from the pylorus was selected for the
gastrostomy site. We measured the abdominal wall and selected a 12-
French 1.0 cm MIC-KEY button as an appropriate size for this patient.
We then placed a stay suture in the stomach in the location of the
gastrostomy button placement. A 4-0 Vicryl was then used to create a pursestring
type suture. Three additional serosa to abdominal wall sutures were
placed. We then made a small gastrotomy. An appropriate position in
the abdominal wall was identified and opened and a hemostat was
placed through this area. We then placed the button through the
abdominal wall into the gastrotomy and blew up the balloon with 3 mL
of sterile water. The pursestring suture followed by the abdominal
wall sutures were then tied down. A final 4-0 Vicryl serosa to
abdominal wall suture was then placed inferiorly. The balloon of the
button sat in appropriate position of the stomach based on palpation.
We then again copiously irrigated the abdomen. Seen excellent
hemostasis. We proceeded to closure. It should be noted that a
short-segment skin flap was made circumferentially around the
incision. This did involve lifting the umbilicus off the fascia in
order to create a good fascial closure. We took care to prevent the
skin flap in the gastrostomy site from connecting. A 3-0 running PDS
sutures were then used to close the abdomen. The umbilicus was then
tacked back down to the fascia to create a neoumbilicus. Marcaine
was placed throughout the operative field (0.25% Marcaine plus
epinephrine diluted half). A running 5-0 subcuticular suture was
then placed. Mastisol and Steri-Strips were then placed. The
dressing was placed on the G-tube site. This concluded the
operation. The patient tolerated this procedure well. All needle,
sponge, and instrument counts were reported as correct at the end of
the procedure. I was present for and performed the entire operation.
The patient was taken back to the NICU intubated in stable condition.
I updated the patient's family as to the outcomes of the surgery
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