OPERATION PERFORMED: Laparoscopic robotic-assisted Roux-en-Y gastric bypass with intraoperative upper endoscopy.
DESCRIPTION OF OPERATION: After adequate oral endotracheal anesthesia was administered, the patient was prepped and draped in routine sterile fashion in a supine position with both arms abducted. The patient did receive 5000 units of heparin subcutaneously in the preoperative area and had sequential compression devices placed and activated prior to the induction of anesthesia. Additionally, the patient did receive a single dose of intravenous antibiotics prior to the first skin incision and had a Foley catheter placed after the induction of anesthesia. The operation was begun by anesthetizing the skin superior to the left of the umbilicus with 0.5% Marcaine plain. Saline draw test revealed the needle to be in proper location. The abdomen was insufflated with carbon dioxide gas to 18 mmHg pressure. The needle was removed. A 12 mm visualizing trocar was placed into the abdomen. Once this was completed, a 45-degree angled telescope was used to explore the abdomen. There were no gross abnormalities noted. Subsequently, an 8 mm robotic trocar was placed in the left subcostal anterior axillary line. A 5 mm trocar was placed in the left mid abdomen. A 12 mm trocar was placed in the right mid abdomen. An 8 mm robotic trocar was placed in the right subcostal midclavicular line. The Nathanson liver retractor was placed through the subxiphoid incision. The operation was begun by dividing the omentum vertically at the level of the ligament of Treitz up to the transverse colon. This was done using a Harmonic scalpel and the Echelon 60 stapling device with 2.5 mm staples with Seamguard reinforcement.
Once this was completed, the ligament of Treitz was identified and a point 60 cm distal to this was selected. The bowel was divided transversely at this point using Echelon 60 stapling device with 2.5 mm staples with Seamguard reinforcement. A second firing of the stapler was carried out into the mesentery to facilitate mobilization of the sutured Roux limb. Once this was completed, a point 125 cm to this was selected and a side-to-side jejunojejunostomy was carried out. Stay sutures of 2-0 Surgidac suture were placed. The enterotomies were created using the Harmonic scalpel. The side-to-side anastomosis was created using Echelon 60 stapling device with 2.5 mm staples and no reinforcement material. The open end of the anastomosis was closed transversely using Echelon 60 stapling device with 2.5 mm staples with Seamguard reinforcement. Mesenteric defect was closed using a running 2-0 Surgidac suture. The proximal Roux limb was brought up to the proximal stomach and found to reach without difficulty. Once this was completed, attention was turned to the stomach. Peritoneal attachments to the angle of His were taken down using a Harmonic scalpel. The gastrohepatic omentum was opened using a Harmonic scalpel. The lesser curve neurovascular bundle was divided in continuity using the Echelon 60 stapling device with 2.5 mm staples and Seamguard reinforcement. The horizontal transection of the stomach was carried down using Echelon 60 stapling device with 3.5 mm staples and no reinforcement. The vertical transection of the stomach was carried out using Echelon 60 stapling device with 3.5 mm staples and Seamguard reinforcement. Subsequent to this time, the proximal Roux limb was brought up to the pouch and held in place with a single interrupted 2-0 Surgidac suture placed with the Endo Stitch device.
At this point, the robotic portion of the operation was begun. The da Vinci robotic assistance was brought to the operating room table and docked to the operating trocars without difficulty. The operation was begun using the da Vinci assistance by placing a single row of posterior running 2-0 Ethibond suture. The gastrotomy and enterotomy were created using the da Vinci robotic scissors as well as electrosurgical cautery. The endoscope was passed through the orifice of the stomach and the orifice of the small intestine to ensure adequate size of the anastomosis. Once this was completed, the inner layer of the anastomosis was completed by placing a posterior row of running 2-0 Vicryl suture. The anterior layer of the anastomosis was closed over the endoscope using a running 2-0 Vicryl suture. The anterior portion of the anastomosis was imbricated along its length using a running 2-0 Ethibond suture. Once this was completed, a bowel clamp was placed on the Roux limb. Insufflation with the endoscope revealed no leakage of air under a fluid level of sterile saline. The anastomosis was patent and not bleeding.
Once this was completed, the proximal Roux limb and pouch were desufflated. The endoscope was removed. The da Vinci robotic assistant was removed from the operating room table without difficulty. The Tisseel tissue adhesive was placed over the anterior and lateral aspects of the anastomosis. A 10 mm flat drain was placed posterior to the anastomosis and brought out through the right subcostal midclavicular line trocar site. Once this was completed, the 12 mm port sites were closed at the fascial level using the Carter-Thomason port closure device and 0 Vicryl suture. The skin incisions were closed using a running 4-0 Monocryl subcuticular closure. Benzoin and Steri-Strips were applied. All sponge, needle, and instrument counts were correct at the end of the procedure.
DATE OF PROCEDURE: MM/DD/YYYY
1. Esophageal leak.
2. Esophagocutaneous fistula.
3. Status post Ivor-Lewis esophagogastrectomy.
4. History of esophageal cancer.
1. Esophageal leak.
2. Esophagocutaneous fistula.
3. Status post Ivor-Lewis esophagogastrectomy.
4. History of esophageal cancer.
Esophageal stent placement.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
INDICATIONS FOR PROCEDURE: This is a patient who underwent Ivor-Lewis esophagogastrectomy. He developed postoperative leak that was explored and repaired, including a muscle flap placement. He did well and was discharged to home. He recently was admitted with controlled esophagocutaneous fistula that was verified on swallow study. The patient had no signs of sepsis; therefore, the plan was to control this to decrease the output of this fistula by placing a stent with the fact that this might allow the fistula to seal. Of note, there is no evidence of malignancy, distal obstruction or other reasons to prevent fistula healing.
DESCRIPTION OF PROCEDURE: The esophagogastric anastomotic separation was identified via upper GI endoscopy and accounted for approximately one-third of the circumference of the anastomosis. We, therefore, felt that stent placement was appropriate. A wire was placed across the anastomosis into the stomach under endoscopic visualization as well as under fluoroscopy. The scope was removed leaving the wire in place. A 22 mm diameter Alimaxx completely covered each mandible. Esophageal stent was then placed by the delivery system across the anastomosis under fluoroscopic visualization. After locating the mid point of this stent at the anastomosis, it was deployed without difficulty. Post-deployment fluoroscopy showed appropriate placement, gently placing the scope back in and verifying the location of the stent suggested appropriate placement.
OPERATION PERFORMED: Laparoscopic Nissen fundoplication.
DESCRIPTION OF OPERATION: After adequate oral endotracheal anesthesia was administered, the patient was prepped and draped in a routine sterile fashion in the lithotomy position with both arms adducted. The patient did receive a single dose of intravenous antibiotics prior to the first skin incision and did have sequential compression dressing placed and activated prior to the induction of anesthesia. Operation was begun by anesthetizing the skin superior to the left of the umbilicus with 0.5% Marcaine plain. A vertical skin incision was made.
The Veress needle was placed into the peritoneal cavity. A saline drop test revealed it to be in proper location. The abdomen was insufflated with carbon dioxide gas to 15 mmHg. The needle was removed and a 12 mm Optiview trocar was placed into the abdomen. Exploration showed no gross abnormalities. Subsequently, the other trocars were placed in a standard fashion. A 5 mm trocar was placed in the left subcostal anterior axillary line. A 10 mm trocar was placed in the left subcostal midclavicular line. A 5 mm trocar was placed in right subxiphoid location. A 5 mm trocar was placed in the right subcostal anterior axillary line. The operation was begun by elevating the liver with the Endoflex liver retractor and placed in a self-retaining retractor holder. The omentum was dissected off the greater curvature of the stomach from approximately the mid body of the stomach up to the peritoneal attachment at the angle of HIS to the left crus of the diaphragm. This was completed with a Harmonic scalpel taking special care to ensure hemostasis. The lesser omentum was opened using a Harmonic scalpel. The right crus and the left crus of the diaphragm were both identified and dissected from the apices to the base. The phrenicoesophageal ligament was divided using the Harmonic scalpel.
Once complete, circumferential mobilization of the gastroesophageal junction was accomplished. The mediastinal dissection was carried out using blunt dissection and the Harmonic scalpel for hemostasis. Once adequate dissection was achieved, the closure was carried out using two interrupted 2-0 Surgidac sutures using the Endo Stitch device. It should be noted that the inflatable balloon bougie was placed into the esophagus by Anesthesia. This was inflated to the size of approximately 52 French bougie. Once this was completed, the fundoplication was carried out in standard fashion after placing the fundus through the retroesophageal window. There was good and easy passage of the fundus and it stayed in place without any tension. The fundoplication was carried out in standard fashion using two interrupted 2-0 Surgidac sutures to create the fundoplication. Both sutures incorporated a small bite of the esophageal muscular wall.
Once this was completed, the bougie was in place and was easily removed, hemostasis was assured. Once hemostasis was ensured, the 10 mm port sites were closed using the Carter-Thomason port closure device and 0 Vicryl suture. The skin incisions were all closed using 4-0 Monocryl subcuticular closure. Benzoin and Steri-Strips were applied. The patient tolerated the procedure well and was returned to the recovery room in stable condition.
OPERATION PERFORMED: Laparoscopic long limb Roux-en-Y gastric bypass and esophagogastrojejunoscopy with endoscopic placement of circular stapler anvil.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the table in a supine position. Foot compression devices were applied to the patient's feet and compression was initiated and not discontinued until the end of the operation. The patient was then placed under general anesthesia via endotracheal tube. A right internal jugular triple-lumen catheter was placed. A Foley catheter was placed and the patient's abdomen was prepped and draped in a sterile fashion. The patient did receive preoperative IV antibiotics. Local anesthetic was infiltrated into all trocar wounds prior to their creation. A 12 mm port was introduced several inches above the umbilicus. It was not introduced through the umbilicus because of the patient's large abdominal pannus. The umbilicus was far too low to perform the operation. The trocar was introduced under direct vision. The remaining trocars were then placed. A 5 mm trocar wound was created in the subxiphoid region in the midline and removed and exchanged with the Nathanson liver retractor. The left lobe of the liver was elevated, but the patient was noted to have extensive hepatomegaly and exposure of the underlying stomach was quite poor with limited overhead clearance. A second 5 mm trocar was introduced in the left subcostal region. A total of three additional 12 mm trocars were introduced, two in the medial inferior bilateral upper quadrants and one in the right subcostal region. The gastrohepatic ligament was opened with the Harmonic scalpel. A Jackson-Pratt drain was placed in through the gastrohepatic ligament into what we felt was the lesser sac.
Next, the transverse colon and omentum were elevated superiorly. Adhesions were lysed with Harmonic scalpel. This allowed the omentum to be elevated superiorly demonstrating the transverse mesentery. The ligament of Treitz was identified and the transverse mesentery was opened just anterior into the left of the ligament of Treitz. The lesser sac was entered and an attempt to find the Jackson-Pratt drain was unsuccessful. After several attempts to pass it, we abandoned this approach. The proximal jejunum was measured out to approximately 30 cm from the ligament of Treitz. Here, the bowel was divided with a single firing of the endoscopic stapler with a white load completely dividing the bowel, but no mesentery. A 150 cm of Roux limb was then measured out and a side-to-side jejunojejunostomy was constructed between the distal end of biliopancreatic limb and the distal end of the Roux limb. The anastomosis was constructed along the anterior mesenteric border of both loops of bowel with a single firing of the 60 mm endoscopic stapler with a white load. The resultant opening was closed with two firings of the same stapler. Anastomosis was inspected and noted to be widely patent, both across the anastomosis and from the Roux limb to the common channel. Next, an antiobstruction stitch was placed with a nonabsorbable 2-0 suture. The tourniquet was then available and it was placed through the gastrohepatic ligament into the lesser sac. Transverse colon and mesentery were elevated and the opening in the transverse mesentery was exposed. The blue tourniquet was retrieved and pulled through the mesenteric window. It was then sutured to the proximal end of the Roux limb with a figure-of-eight 2-0 silk. The proximal end of the Roux limb was inserted into the lesser sac and pulled to the lesser curvature of the stomach through the gastrohepatic ligament. Proximal stomach was then examined. The angle of His was dissected along the left crura of the stomach. The stomach was then gauged with a Baker tube inserted into the stomach and inflated with 20 mL of air. Balloon was pulled back to the gastroesophageal junction and a 15 mL pouch was planned. The Baker tube was deflated and removed. The sac and neurovascular bundle along the lesser curvature was dissected away from the lesser curvature around the site of the stomach and onto the posterior surface of the stomach and into the lesser sac. The stomach was then sequentially divided with two firings of the 60 mm endoscopic stapler with blue load.
Next, esophagogastroscopy was performed. This pouch was noted to be of appropriate size. A long spinal needle was inserted through the anterior abdominal wall into the peritoneal cavity and then into the gastric pouch just posterior to the staple line. A guidewire was passed through the spinal needle into the gastric pouch and grasped with a snare. The guidewire was then pulled up the esophagus to the mouth where it was attached to the anvil of a 21 mm EEA stapler. The anvil was then pulled down the esophagus with minimal difficulty and into the gastric pouch. The anvil post was delivered through the posterior gastric wall with limited use of electrocautery around the guidewire. Next, the proximal end of the Roux limb was opened along the staple line with the Harmonic scalpel. The guidewire was removed from the anvil post. The inferior medial left upper quadrant trocar wound was then dilated manually with the smallest of the EEA sizers and two 0 PDS sutures were placed across the fascial and peritoneal defect with the endoscopic closure device. The 21 mm stapler was then inserted into the peritoneal cavity into the opened end of the Roux limb and 4 cm down the Roux limb. It was directed against the antimesenteric border and the spike was delivered through that wall of the bowel. It was linked with the EEA anvil post, and the stapler was closed in minimal staple height and fired. The stapler was then extracted, irrigated, and pulled out of the peritoneal cavity through the black sheath to avoid contamination of the subcutaneous fat. The open end of the Roux limb was closed with a single firing of the 16 mm endoscopic stapler with a white load and this also removed the Penrose drain.
Next, the anterior 300 degrees of the gastrojejunostomy was oversewn with Lembert style absorbable 2-0 silk sutures. This also obliterated the space between the gastrojejunostomy staple line and the gastric division staple line. The transverse colon and mesentery were elevated superiorly. The redundant portion of the Roux limb was pulled below the transverse mesentery. The Roux limb was then sutured to the mesenteric window with a running 2-0 silk suture to avoid internal herniation. The Roux limb was occluded just below the mesenteric window and esophagogastrojejunoscopy was performed. The gastric pouch was insufflated until the patient began to eructate. No bubbles were noted coming through the staple line as the pouch was examined in the peritoneal cavity under irrigation. The scope was passed across the anastomosis down the Roux limb, and the insufflating gas was aspirated as the scope was pulled back. The operation was completed after inspecting the peritoneal cavity. The gallbladder could not be visualized despite placing the patient in reverse Trendelenburg with the left shoulder down.
Two 19 French round Blake drains were placed in the peritoneal cavity and brought out through the two subcostal trocar wounds. The drains were placed under the left lobe of the liver near the gastrojejunostomy but not on it. The left drain was placed under the left hemidiaphragm. Peritoneal cavity was aspirated free of irrigation and the limited blood irrigation was then performed and the aspirate was clear. The trocars were removed under direct vision to ensure adequate hemostasis and pneumoperitoneum was evacuated. Local anesthetic was infiltrated into all of the trocar wounds and additional local anesthetic was put down the drains into the peritoneal cavity. The anesthetic used was a 50:50 mix of 0.5% Marcaine with epinephrine and injectable saline. The two Blake drains were secured to the skin with 3-0 nylon suture.
All skin wounds were then closed. The inferior medial left upper quadrant trocar wound was closed by tying the previously placed 0 PDS sutures and this adequately closed the fascial and peritoneal defect. Skin was reapproximated with interrupted running subcuticular 5-0 Monocryl. The wounds were then dressed with tincture of benzoin, Steri-Strips, Telfa, and Tegaderm. Drain sites were dressed with dry gauze and tape. The patient tolerated the procedure well and was extubated postoperatively and transported to the recovery room in stable condition.