Procedures:
* EXPLORATORY LAPAROTOMY, abdominal washout, intraoperative diagnostic gastroscopy, gastrojejunostomy tube placement, closure with incisional VAC
Specimens:
No Specimens Collected During Procedure
January 7, 2023 patient identified in the preop area. Consent was on the chart. Preop antibiotics had already been initiated. Patient was then brought back to the operating room placed in supine position operating table. Patient placed under generalized endotracheal anesthesia monitor as per Anesthesiology. Patient's abdomen was then prepped draped usual sterile fashion using Betadine. Time-out procedure was then completed. The previously placed skin staples were removed. We were then able to open up to the fascia quite readily. The PDS suture in place was then able to be cut the fascia was able to be opened quickly and a large amount of bilious fluid was expressed. We were able to suction out several liters of the fluid in all 4 quadrants. At this point we were then able to irrigate out all 4 quadrants with copious amounts of sterile normal saline solution. At this point with blunt dissection were able to free up the stomach and duodenal anastomosis from the liver the transverse colon and the omentum. We will to identify the previous so suture lines as well as the plication that was done along the upper portion of the stomach. We were not able to overtly identify any perforation or active leak at this point. At this point then I was able to step away and complete the intraoperative diagnostic gastroscopy. The endoscope was able to be passed through the oropharynx through the esophagus I did encounter some bilious fluid that was able to be completely removed. I traversed through the GE junction into the stomach and again identifying bilious fluid. I was then able to identify the gastroduodenal anastomosis traversed through this into the duodenum for long distance and identifying that the tissues were healthy pink and viable. I was able to withdraw back into the stomach and again identifying the anastomosis and along the posterior wall we able to identify what looked like an area of the perforation. Since it was posterior patient had likely sealed this in the interim. The remaining portion of the stomach anastomosis and duodenum were healthy pink and viable. We completed a leak test with the endoscope and CO2 with the pressure and there was no leak visible. Again confirming that likely this area had opened and sealed because of the posterior position. At the same time then we decided that a gastrojejunostomy tube placement would be prudent as we would be able to decompress the stomach as well as have the tube go past the ligament of Treitz for a ventral tube feeds for nutrition and medications. Via a separate stab incision along the left upper quadrant our gastrojejunostomy tube was able to be placed and then a pursestring of 3-0 silk sutures was then placed along the upper portion of the greater curvature of the stomach. Then using electrocautery we able to make our gastrotomy. This was completed by Dr. ___. The gastrojejunostomy tube was able to be then inserted. At the same time I was able to graft this with the endoscope and bring it through the gastroduodenal anastomosis and down past the ligament of Treitz. Dr. __ was able to palpate this that we were well past the ligament of Treitz at this point. The balloon was then distended. CO2 insufflation was then released and the endoscope was withdrawn. At this point we were then able to progress with washout and drain placement. Again the abdomen was irrigated out with copious amounts of sterile normal saline solution. We were then able to place a 19 Blake drain along the gastroduodenal anastomosis in the posterior aspect via a left mid incision. A 2nd 19 French Blake drain was then placed into the pelvic area via a right lower quadrant separate stab incision. Both of these were secured to the skin using the 3-0 nylon suture. At this point given the swelling and inflammation it was difficult to reapproximate the fascia. We then decided at this point to reapproximate the skin and allow secondary intention healing. And then incisional VAC with white foam black foam would be placed on top. The gastrojejunostomy tube was then placed to gravity drainage. Procedure was then completed at this point. Patient was awoken from the anesthesia extubated stable condition transferred to recovery area. All counts correct at the end of the case.
Requesting opinions please.... laparotomy w/ wound VAC or open gastrojejunostomy tube placement w/ wound VAC? Please and thank you!
* EXPLORATORY LAPAROTOMY, abdominal washout, intraoperative diagnostic gastroscopy, gastrojejunostomy tube placement, closure with incisional VAC
Specimens:
No Specimens Collected During Procedure
January 7, 2023 patient identified in the preop area. Consent was on the chart. Preop antibiotics had already been initiated. Patient was then brought back to the operating room placed in supine position operating table. Patient placed under generalized endotracheal anesthesia monitor as per Anesthesiology. Patient's abdomen was then prepped draped usual sterile fashion using Betadine. Time-out procedure was then completed. The previously placed skin staples were removed. We were then able to open up to the fascia quite readily. The PDS suture in place was then able to be cut the fascia was able to be opened quickly and a large amount of bilious fluid was expressed. We were able to suction out several liters of the fluid in all 4 quadrants. At this point we were then able to irrigate out all 4 quadrants with copious amounts of sterile normal saline solution. At this point with blunt dissection were able to free up the stomach and duodenal anastomosis from the liver the transverse colon and the omentum. We will to identify the previous so suture lines as well as the plication that was done along the upper portion of the stomach. We were not able to overtly identify any perforation or active leak at this point. At this point then I was able to step away and complete the intraoperative diagnostic gastroscopy. The endoscope was able to be passed through the oropharynx through the esophagus I did encounter some bilious fluid that was able to be completely removed. I traversed through the GE junction into the stomach and again identifying bilious fluid. I was then able to identify the gastroduodenal anastomosis traversed through this into the duodenum for long distance and identifying that the tissues were healthy pink and viable. I was able to withdraw back into the stomach and again identifying the anastomosis and along the posterior wall we able to identify what looked like an area of the perforation. Since it was posterior patient had likely sealed this in the interim. The remaining portion of the stomach anastomosis and duodenum were healthy pink and viable. We completed a leak test with the endoscope and CO2 with the pressure and there was no leak visible. Again confirming that likely this area had opened and sealed because of the posterior position. At the same time then we decided that a gastrojejunostomy tube placement would be prudent as we would be able to decompress the stomach as well as have the tube go past the ligament of Treitz for a ventral tube feeds for nutrition and medications. Via a separate stab incision along the left upper quadrant our gastrojejunostomy tube was able to be placed and then a pursestring of 3-0 silk sutures was then placed along the upper portion of the greater curvature of the stomach. Then using electrocautery we able to make our gastrotomy. This was completed by Dr. ___. The gastrojejunostomy tube was able to be then inserted. At the same time I was able to graft this with the endoscope and bring it through the gastroduodenal anastomosis and down past the ligament of Treitz. Dr. __ was able to palpate this that we were well past the ligament of Treitz at this point. The balloon was then distended. CO2 insufflation was then released and the endoscope was withdrawn. At this point we were then able to progress with washout and drain placement. Again the abdomen was irrigated out with copious amounts of sterile normal saline solution. We were then able to place a 19 Blake drain along the gastroduodenal anastomosis in the posterior aspect via a left mid incision. A 2nd 19 French Blake drain was then placed into the pelvic area via a right lower quadrant separate stab incision. Both of these were secured to the skin using the 3-0 nylon suture. At this point given the swelling and inflammation it was difficult to reapproximate the fascia. We then decided at this point to reapproximate the skin and allow secondary intention healing. And then incisional VAC with white foam black foam would be placed on top. The gastrojejunostomy tube was then placed to gravity drainage. Procedure was then completed at this point. Patient was awoken from the anesthesia extubated stable condition transferred to recovery area. All counts correct at the end of the case.
Requesting opinions please.... laparotomy w/ wound VAC or open gastrojejunostomy tube placement w/ wound VAC? Please and thank you!