op note help needed!!

herrera4

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Wallingford, CT
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this patient has no bariatric coverage-dr. wants to put through as gastrectomy-im seeing revision of bypass

can anyone help? I know op note is lengthy but any help is appreciated!!

Specimens Removed and Size: 2 specimens. The first was the gastrojejunostomy with a posterior penetrating ulcer. The anastomosis had marked inflammatory changes and a large amount of Prolene suture material. The second specimen was a portion of gastric pouch from the redundant gastric pouch remodeling..
Findings: There was extensive adhesive disease between small bowel loops and also between the omentum stomach liver and diaphragm. The pouch and gastric remnant were also tightly adhesed. Extensive and prolonged adhesive lysis was required. The pathology that was identified is a penetrating posterior ulcer at or just distal to the gastrojejunostomy which was at the level of the mesocolic window. Following resection of the gastrojejunostomy a large amount of suture material could be seen at the anastomotic site and provided a clear recommendation wide persistent stricturing and ulceration was occurring in this patient. With this definitive evidence I elected to revise the gastrojejunostomy rather than completely removing the Roux limb and restoring her original anatomy..
Counts: Sponge counts, needle counts and instrument counts were correct at the conclusion of the procedure.
Peri-Operative Event and/or Complications: None.

Operative Note
The patient was placed in supine position under general anesthesia service performed. Preoperatively the patient received IV antibiotics and subcutaneous heparin as well as initiation of foot pumps for DVT prophylaxis.
A timeout procedure confirming the surgical site and the intended operation and patient identification.
Incision was made in the left upper quadrant at approximately the level of the left pelvic rim. A 5 mm optical trocar was introduced and the the abdomen was entered under direct vision a 5 mm scope. We then insufflated to 15 mmHg CO2 gas without hemodynamic compromise. Under direct vision we then placed an 8 mm da Vinci trocar in the right midabdomen anterior axillary line, a 12 mm air seal trocar in the right midclavicular line at the level of the umbilicus, a 12 mm noncutting self-retaining balloon trocar just to the left of the midline supraumbilically, replaced the 5 mm trocar with a da Vinci 8, and place an additional 8 mm da Vinci trocar in the left anterior axillary line.
The robot was then docked and dissection begun. We started with sharp dissection of the aforementioned adhesions which were taken down completely exposing the hiatus. Sharp dissection continued to free the gastric cardia from the diaphragm. The pouch and remnant were identified and in order to identify the gastrojejunostomy I took down this adhesive attachment. The lesser sac was entered by opening the gastrohepatic ligament. The right crus was exposed and there was no hiatal hernia. Dissecting this region I was not able identify a clear delineation of the gastrojejunal anastomosis. Therefore I opened the gastrocolic ligament and entered the lesser sac along the greater curve. There is able to identify the pouch and descending Roux limb though the anastomosis still was not clear.
The omentum was reflected cephalad and I performed extensive adhesio lysis of the small bowel from the transverse mesocolon ultimately exposing the ligament of Treitz. I then was able to identify the descending Roux limb which was immediately anterior to the ligament of Treitz. There were dense adhesions and there was edema and inflammatory change in the posterior left aspect at the mesocolic window. I decided this point divided descending Roux limb with a green GIA stapler. This allowed me to see posteriorly to the posterior mesocolic window. Performing dissection here I was able identify the penetrating posterior ulcer. There is no bleeding. Looking in through the ulcer I was able see that the anastomosis was about a centimeter proximal with extensive inflammatory changes, stricturing, and a large length of running Prolene suture. I used sharp dissection and the Harmonic scalpel to free the descending Roux limb circumferentially. I ultimately exposed the posterior pouch. I divided the pouch about 1-2 cm proximal to the gastrojejunostomy. The specimen was placed in a bag.
I then returned to the upper abdomen and inspected the pouch. It appeared to be fairly long though not particularly wide. I did resect another 2 cm as a separate specimen. Again a green GIA stapler was used. I then elevated the divided Roux limb back up through the transverse mesocolon.
A 2 layer anastomosis using 2-0 Vicryl was created between this gastric pouch and Roux limb. After sewing an initial posterior row of 2-0 Vicryl created a 1-1/2 cm gastrojejunostomy with the Harmonic scalpel. An internal row of Vicryl was sewed and a orogastric tube was passed down into the descending Roux limb confirming patency. I then completed the exterior row and performed distal compression of the descending Roux limb. The anesthesiologist administered methylene blue dye to 1 m column. Infusion of the blue dye continued until there was documented gastro-oral reflux without staple line or anastomotic leakage.
I inspected the pouch closely and also the gastric remnant. The staple line of the gastric remnant had some bile staining to it. There is no overt mucosal exposure. However there clearly were some small pinhole violations to the gastric wall along the staple line. Therefore performed a running imbrication using 2-0 Vicryl to oversew the entire cut surface of the gastric remnant where it had been freed from the pouch. There is no evidence of injury to the pouch under the inspection.
Again attention was turned to the lower abdomen with reflection of the omentum cephalad and the mesocolic window was sutured to the descending Roux limb in a running fashion using 2-0 silk. This closure incorporated Peterson's defect which was closed in entirety. Again hemostasis was confirmed and then the omentum was reflected back into its normal position and the lower abdomen. A JP drain was then placed through the right lateral trocar site and placed to drain the region of the pouch and remnant and parasplenic region. All trochars and instruments were removed at this point and the abdomen desufflated.
The fascia was closed at the 12 mm port sites using 0 Vicryl.
Skin sites were all closed with skin staples. The procedure was completed without complication and all instrument counts were correct at the conclusion of the procedure.
 
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