Lap repair gastric perforation

nlbarnes

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PROCEDURES:
Exploratory laparotomy, repair of posterior gastric perforation,
Vicryl mesh placement, wound VAC placement.

INDICATIONS:
The patient is a 46-year-old female, who is now postop day 7 from a
reoperation for ileo to distal sigmoid anastomotic leak, who has developed a
new leakage of bowel contents into the abdominal cavity in large amounts,
which cannot be controlled with drains and she presents for surgery.

DESCRIPTION OF PROCEDURE:
After the induction of suitable general endotracheal anesthesia, with
the patient in the supine position, the abdomen was prepped and
draped. The staples were removed. The ileostomy bag was removed.
The rod underneath the ileostomy was removed and the suture on the
percutaneous drain was removed and later in the case the drain was completely
removed. We then prepped and draped in the usual sterile fashion with
ChloraPrep, followed by, to the ileostomy, Betadine. The sutures in the
fascia were removed and immediately, bowel contents came out of the midline
incision. We suctioned this out and continued removing the sutures. The
small bowel was thick and distended mild-to-moderately, not severely distended
and covered with fibrinous exudate and friable. We very carefully
manually separated the bowel from the anterior abdominal wall. All of these
adhesions were very soft. We then very carefully finger separated all the
small bowel loops. We identified the ileostomy and followed that bowel down
distally to the ileal to distal sigmoid anastomosis and there did not appear
to be any leakage there and our suture line appeared intact. We then found
the proximal side of the ileostomy and followed the bowel proximally.
Eventually, we identified the site of the small hole that we had sutured in 2
layers at the previous surgery and that appeared completely intact. We
checked carefully the back wall at this site and that appeared normal. We ran
the small bowel all the way up and down and washed out the abdomen thoroughly.
We looked over by the duodenum, which of course is the opposite side from
where most of the succus had been on scan and we could not see any evidence of
injury. We then in order to fully work with the stomach better, opened the
midline incision up higher. At this point, the surface of the stomach looked
somewhat friable on the superficial aspect. We held up and looked at the
deep aspect and could not see an obvious hole. However, given where all the
fluid was on the left side and in the left upper quadrant on the initial CT
scan, where we had identified this leak, we elected to place a lap pad behind
the stomach and a lap pad in front of the stomach and then we had the
anesthesiologist put methylene blue saline down the NG-tube. We noted
methylene blue fluid welling up into the wound and then we looked at our lap
pads and we were able to identify that it was coming from the posterior
stomach and lifting that way up and looking underneath, we saw about 1-cm
defect in the middle proximal area of the posterior wall of the stomach. At
this point, we asked the anesthesiologist to place a new NG-tube and he
passed it down and the tube went directly out the hole with no effort at all
by him. We had him pull it back and then we redirected the tube manually down
more distally in the stomach. There was some oozing, bleeding from the edges
of the wound in the stomach and some of the retroperitoneal tissues, but we
could not identify any bleeding from the spleen itself. We placed some
FloSeal and packed that area. We then worked on closing the stomach, which we
did with 2 layers of interrupted 3-0 silk sutures, the first was to
approximate the stomach hole edges and the second as a set of Lembert
sutures to fold in that suture line and care was taken to avoid catching
the NG-tube in the sutures and we had the anesthesiologist move the tube
afterwards as well and it moved freely. Once that was accomplished, we
removed the lap pad from the left upper quadrant and hemostasis appeared
excellent. We then further washed out the abdomen with multiple liters of
normal saline. We considered placing a gastrostomy tube but felt that the
anterior portion of the stomach was too friable. We did test the gastrotomy
closure with having the anesthesiologist put in another 200 mL of methylene
blue saline and blew up the stomach with that and there was no evidence of
leak from our closure. Then, we considered how to close the abdomen. This
patient has had an abdominoplasty previously and her abdomen is prior to any
surgery quite tight. We decided to place a piece of Vicryl mesh, which I
placed with interrupted #1 PDS sutures burying its edges under the fascia, all
the way around taking care to avoid injury to the bowel and then I elected to
try to close the midline fascia over the mesh, which initially seemed like it
would not be possible, but we started at the top and I was able to use
interrupted figure-of-eight #1 PDS sutures on the anterior rectus fascia and I
was able to bring this fascia together over the mesh. We then got a wound VAC
and placed the black sponge over the fascia. Prior to
closing the midline, we had placed 2 Jackson-Pratt drains into the left side of
the abdomen through the left mid quadrant old port site. These were 19 round
drains, the most superior drain on the body goes into the pelvis and around to
the right lower quadrant, and the most inferior drain on the body goes to the
left upper quadrant. Then, we made a right upper quadrant small incision and
placed another 19 round drain up in the gutter lateral to the liver and all of
these were sewn in with 2-0 nylon.
 
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