Laparoscopic Repair of Gastrojejunal Anastomotic Leak

Danna123

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Help Please.... I'm not sure which code(s) to pick for this procedure.....

PROCEDURE:
Laparoscopic lysis of adhesions (2hrs 30 mins)
Laparoscopic drainage of abscess
Laparoscopic repair of gastrojejunal anastomotic leak
EGD

FINDINGS:
Severe omental adhesions to the anterior abdominal wall.
Transverse colon adhesion to the anterior abdominal wall
Adhesions between the left lobe of the liver and the remnant stomach, gastric pouch
RUQ wound and abscess cavity. Mesh noted deep to wound.
Abscess cavity situated at site of entry of the pigtail catheter in the retrocolic space
Retro-colic, retro-gastric Roux limb
2 cm gastrojejunal leak extending from the right posterior aspect and anteriorly
Negative leak test after repair of the leak
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COMPLICATIONS: None.
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CONDITION: The patient tolerated the procedure well and was transferred in stable condition.
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INSTRUMENT/SPONGE COUNTS: Correct x 2.
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PROCEDURE:
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Patient is a 52 yr old female who had undergone a laparoscopic hiatal hernia repair in addition to revision of her gastric pouch about 3 weeks ago at another hospital. She subsequently developed a leak and was initially managed conservatively with IR drain placement and IV antibiotics. A repeat CT of the abdomen and pelvis showed an abscess cavity that persisted. The IR drain was upsized and still had minimal drainage. The decision was then taken to perform a laparoscopic drainage of the abscess with possible repair of the leak. There was also a plan to possibly place a gastrostomy tube in the remnant stomach. The patient was consented for surgery. The risks and benefits were discussed. Patient was brought into the operating room and placed in the supine position. General endotracheal anesthesia was induced. A foley catheter was placed. The abdomen was then prepped and drained in the standard sterile manner.
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An incision was made in the right periumbilical area (about 15 cm caudal to the xyphoid). A 5mm port was then placed using the optiview technique. CO2 insufflation was commenced to create a pneumoperitoneum. A 5mm 30 degree laparoscope was then introduced and the abdomen was inspected. There were intense omental adhesion in the upper abdomen. The laparoscope was gently used to sweep down some of the adhesion in the LUQ. Enough room was then created for the placement of 2 LUQ ports. The IR drain was left in place. With the laparoscope in the left subcostal margin port the adhesions in the RUQ were then taken down bluntly. Some adhesiolysis was performed with the harmonic. The transverse colon was found adherent to the midline. This was carefully dissected off bluntly. A 5mm right subcostal margin port was placed while a 12 mm RUQ port was placed as well. The RUQ abscess wound was inspected. It was seen to have mesh within the fascial layers and visible intraperitoneally. This was left alone to be inspected at the end of the case.
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Attention was turned to the left upper quadrant IR drain. It was noted to be encapsulated in fibrous tunnel. The fibrous casing was incised with the harmonic. The drain was then exposed and seen to be entering a phlegmonous cavity that was seen to be retrocolic and possibly communicating with the lesser sac. The Roux limb was seen to be adjacent this space. It was noted be running in a retrocolic, retrogastric manner. There were intense adhesions involving the left lobe of the liver and the remnant stomach. This adhesions were bluntly dissected off. Eventually the caudate lobe was visualized. The decision was then made at this point to perform an EGD to assist with identifying the site of the leak. The EGD was introduced transorally with the bed placed in the supine position. As it was advanced down the esophagus there were massive bubbles seen to be coming anteriorly from the region of the gastric pouch. The Roux limb was then entered with the endoscope. The endoscope was subsequently withdrawn.
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Further dissection around the area of the pouch and the left lobe of the liver was performed. This was done bluntly in a meticulous manner. Eventually the gastric pouch was noted. There was a cavity noted in the pouch. There was also exposed jejunal mucosa along with staples noted in this area. The endoscope was re-inserted and seen to come through what was a gastrojejunal leak. The leak extended from the right posterior margin for about 2 cm anteriorly. The endoscope was then passed into the Roux limb and left in place to act as a stent during repair. The wound edges were freshened to healthy tissue on both the gastric and jejunal sides. The surrounding tissues were dense and sort of adherent to the remnant stomach.
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The leak was then repaired with an inner layer of interrupted 2-0 polysorbs using the endostitch with intra-corporeal knott tying. The corner of the defect was difficult to apply the endostitch to due to thickness of the tissue. A 2-0 vicryl stitch on SH needle was employed for this repair. 2 such stitches were required. The outer layer consisted of buttress sutures using the serosa of the remnant stomach sewn to the gastric pouch. 2-0 surgidacs were required for this. Insufflation of the Roux limb was then performed via the EGD. The region of the repair was flooded with water. The endoscope was gradually withdrawn to the pouch. The repair was seen to be intact. There was no leak noted. The endoscope was reintroduced into the Roux limb without any luminal narrowing. Finally, the endoscope was removed after it was satisfactorily shown that there was no leak.
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Tisseel was then applied to the repair. The IR drain was completely removed while the tract was exposed further. The abscess cavity was suctioned and irrigated. Two # Jackson Pratt drains were placed in the LUQ (one in the left anterior aspect of the pouch, the other within the retrocolic abscess cavity), while one was place via the right subcostal margin incision (anterior to the repair). The drains were secured to the skin with 3-0 nylon sutures. Due to the use of the remnant stomach to buttress the anastomotic leak the decision was made to avoid performing a gastrostomy tube as this might place some counter-traction on the remnant stomach and jeopardize the repair. RUQ abscess wound was inspected with the aid of Army-Navy retractors. Some suture material deep within the fascia were removed. However, the decision was taken to leave the mesh alone since it was not certain that it was infected. The ports were then removed under direct visualization while CO2 insufflation was discontinued. The RUQ wound was packed with a 3" Kling. The rest of the skin incisions were closed with staples.
 
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