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Gastroenterology Samples

Esophagogastroduodenoscopy with biopsies.

PREOPERATIVE DIAGNOSIS:  Epigastric pain.

POSTOPERATIVE DIAGNOSIS:  Gastritis.

PROCEDURE:  Esophagogastroduodenoscopy with biopsies.

RESIDENT SURGEON:  

ANESTHESIA:  Intravenous sedation. 

INDICATIONS FOR PROCEDURE:   

DETAILS OF PROCEDURE:  With the patient well sedated in left lateral decubitus position, the esophagogastroduodenoscopy scope which introduced easily into the upper esophagus and advanced under direct vision down to the gastroesophageal junction which appeared to be entirely normal. 

The scope was advanced into the stomach and air was insufflated into the stomach.  The patient was noted to have significant gastritis in the midportion of the stomach and down into the antrum.  No ulcers were seen throughout the stomach.  The scope was advanced down into the first, second, and third portions of the duodenum, which were clearly seen and seemed to be free of any pathology. 

The scope was withdrawn back into the antrum and a biopsy for helical bacteria and pathology were taken.  The scope was retroflexed allowing examination of the upper portion of the stomach without any new findings other than the previously noted gastritis. 

The scope was withdrawn to normal position and pulled up through the stomach, again examining the mucosa of the stomach.  The gastroesophageal junction, again, appeared to be normal, as did the entire esophagus. 

The scope was withdrawn and the procedure was tolerated well. 

Colonoscopy.

PREOPERATIVE DIAGNOSIS: Anal polyp.

POSTOPERATIVE DIAGNOSIS: Normal exam.

OPERATION: Colonoscopy.

ANESTHESIA: General.

INDICATIONS: For treating rectal mass.

PROCEDURE: The procedure was explained and a consent form signed. Her parents appeared to have a good understanding of the procedure and its possible complications and were given an opportunity to ask questions.

The patient was brought to the operating suite and anesthetized. In the left lateral decubitus position, the Olympus PCF-160AL video colonoscope was inserted into the rectum under direct vision. The instrument was advanced to the hepatic flexure. The patient tolerated the procedure well and was sent to the recovery room in good condition.

FINDINGS: The rectum and sigmoid were somewhat dilated, suggesting chronic constipation. The mucosal surfaces were smooth and glistening with no evidence of edema, erythema, ulcerations, friability, mass, lesions, or narrowings. 

PLAN: The patient will be continued on MiraLax.

CHOLECYSTECTOMY

PREOPERATIVE DIAGNOSIS: Acute cholecystitis and cholelithiasis.

POSTOPERATIVE DIAGNOSES: Acute cholecystitis and cholelithiasis; severe acute cholecystitis.

OPERATION PERFORMED: Laparoscopic cholecystectomy.

ANESTHESIA GIVEN: General anesthesia.

ESTIMATED BLOOD LOSS: 100 mL.

FINDINGS: The patient had severe acute cholecystitis as noted. The gallbladder was extremely large and inflamed. However, a laparoscopic cholecystectomy was able to be accomplished as will be described below.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was brought to the operating room and was placed in the supine position where general endotracheal anesthesia was induced. The patient's abdomen was prepped with Betadine and draped in the usual sterile fashion.

A supraumbilical approach was chosen, because the patient had a previous hysterectomy and the incision extended all the way up above the umbilicus. The incision was carried through the subcutaneous tissue and then the fascia was identified. Traction sutures of 0-Vicryl were placed. A longitudinal fascial incision was made and the peritoneum was entered bluntly. We were free of adhesions at this point. The Hasson cannula was inserted and the peritoneal cavity insufflated to a pressure of 15 mmHg.

Utilizing the 0-degree laparoscope with the patient in the reverse Trendelenburg position, an additional 11-mm port was inserted into the epigastrium just to the right of the midline. Then 5-mm ports were inserted in the midclavicular and anterior axillary lines, all under direct vision. The gallbladder was identified and there were a few adhesions. It was extremely inflamed and firm. It could not be grasped. For this reason, an 18-gauge Angiocath was placed through the abdominal wall. The gallbladder was held up and this was placed in the gallbladder on the medial aspect next to the fundus. However, the bile was so thick that it could not be aspirated. This was removed and there was some spillage of bile from the needle hole.

A 12-gauge Angiocath needle was then brought into the field and this was also placed in the gallbladder, but again, I could aspirate only about 2-3 cc of fluid. Again, there was some drainage through the hole. The gallbladder was pushed with the forceps and I suctioned a large amount of the bile. A culture was done of the bile. Following this, we were able to grasp the fundus of the gallbladder with Davol forceps. However, the size of the gallbladder made exposure somewhat difficult. I was able to grasp the infundibulum and there was some very edematous infundibular fat which was dissected away and eventually, I was able to identify a structure which I initially thought was the cystic artery but it was somewhat small, but after further inspecting it, I determined it was the cystic duct. It was filling up into the gallbladder. The common duct could be identified. I did not attempt to completely dissect out the cystic duct and common duct junction as we were staying right on the gallbladder.

The duct was singly clipped adjacent to the gallbladder, doubly clipped proximally and divided. Dissection was continued. Some of the veil of cirrhosis was dissected away using the hook cautery setting at 20 watts. With this done, I could appreciate what appeared to be a vascular pedicle. When this was isolated, there appeared to be one branch coursing up onto the gallbladder and this was an anterior artery. This was doubly clipped proximally and singly clipped adjacent to the gallbladder and divided. There was some arterial bleeding at the proximal aspect that did not appear to be completely clipped and an additional clip was placed which controlled this. This was distal to the first two clips.

Again, there appeared to be an anterior and a posterior cystic artery in this area. The dissection was continued using the hook cautery. Another vascular structure was identified and this was able to be clipped with some bleeding.  Dissection at this point was very laborious as the gallbladder was very stuck and the serosa was very thickened. Eventually, with continued dissection, it was able to be removed. One small laceration was made on the right side of the liver using the Davol forceps during this dissection. This appeared to almost stop bleeding. After the gallbladder was removed, the liver bed was inspected and the liver bed was otherwise noted to be hemostatic. The right upper quadrant was irrigated copiously with normal saline solution. A total of two liters of irrigation was used during the procedure.

A small piece of Surgicel was then placed in the field and then placed in the small area of the laceration on the right side of the liver bed. This resulted in good hemostasis. 
The laparoscope was then placed through the epigastric port site and endobag through the infraumbilical port site. The gallbladder was placed in the bag and was brought up into the incision, but the incision was not adequate to remove the gallbladder, so it had to be extended superiorly and inferiorly. Eventually, we were able to remove the gallbladder. It contained two very large stones.

The Hasson cannula was reinserted and the remaining port sites inspected and removed under direct vision. The fascia on the supraumbilical wound was then closed with a total of five interrupted 0-Vicryl sutures. Subcutaneous tissue was irrigated and closed with 4-0 Vicryl sutures and the skin was closed with running 4-0 Vicryl subcuticular suture. The epigastric port site was closed with interrupted buried 4-0 Vicryl sutures and the remaining incisions were closed with Steri-Strips.

All sponge, needle, and instrument counts were reported as correct at the end of the procedure. The patient tolerated the procedure well and left the operating room for the recovery room in stable and satisfactory condition.

BOWEL RESECTION/LAPAROTOMY

PREOPERATIVE DIAGNOSIS: Carcinoid syndrome, mesenteric mass.

POSTOPERATIVE DIAGNOSIS: Carcinoid syndrome, mesenteric mass with multiple liver masses.

OPERATION: Exploratory laparotomy, small bowel resection, mesenteric mass resection, intraoperative ultrasound, and liver biopsy. 

ESTIMATED BLOOD LOSS: 200 mL. 

FLUIDS: IV fluids were 4500 mL. 

COMPLICATIONS: None. 

INDICATIONS: This is a gentleman who was thought to have carcinoid syndrome. He had a CT scan which showed a mesenteric mass. Therefore, he comes in today for an exploratory laparotomy and exploration of mesenteric mass.

PROCEDURE: The patient was brought into the operating room and placed supine on the operating room table. After having SCDs placed to his bilateral lower extremities, the patient was intubated by anesthesia. At this stage in time, the patient’s abdomen was prepped and draped in the normal surgical fashion.

A 10-blade was used to make a midline incision extending superior and inferior along the umbilicus, going to the left of the umbilicus. Once this was done, electrocautery was used to dissect down the subcutaneous tissue down to the fascia. The fascia was opened with electrocautery. The peritoneum was grabbed with 2 toothed forceps and was opened using a 10-blade. At this time, the rest of the fascia was opened under direct vision and over the fingers to protect the underlying organs.

Once this was done, under physical exam, the patient was noted to have a large mass in the mesentery of his small bowel, and he also was noted to have 2 to 3 masses in his small bowel, causing strictures. Therefore, it was opted to see if this was able to be resected at this time. The Bookwalter was then placed on the field and was used to retract the abdominal wall. Once there was adequate exposure, a hand was used to feel up into the field of the liver, and 1 mass was able to be felt. At this time, intraoperative ultrasound was used. The patient was noted to have multiple lesions in the liver.

Due to the constriction of the small bowel and the amount of resection we could get away with, it was felt to undergo a small bowel resection and attempt at the mesenteric mass, which was low down in the mesentery. Therefore, the small bowel distal and proximal to the lesions were resected.  Crile scissors was used to open up the mesentery underneath the small bowel. A GIA stapler was used to transect the small bowel, both proximally and distally. At this time, electrocautery was used to score the mesentery down to the mesenteric mass on both sides of the mesentery and a Crile was used to clamp and tie off the mesentery as we worked our way down to the mass.

Once we came down to the mass, we used the ligature to take the mesentery surrounding the mass. There was some bleeding which was oversewn using 2-0 silk suture stitches. Once this was done, we worked across the base of the mass using the ligature, maintaining hemostasis, and the mass was able to be taken out en bloc with the small bowel.

Once this was done, hemostasis was noted. We turned our attention to the liver. We had to extend the incision approximately 3 cm superiorly using electrocautery. Once this was done, the Bookwalter retractors were repositioned. The liver was pulled down, and the left lobe of the liver was inspected and had multiple lesions that were visualized. Therefore, we took a 15-blade and wedged out a small piece of 1 of the lesions and sent off to pathology. Electrocautery was used to gain hemostasis of the liver.

Once this was done, we reanastomosed the small bowel proximally and distally to the mass. This was done by opening up the small bowel, both distal and proximal, using Mayo scissors on the antimesenteric border of the staple line. The GIA stapler was placed into both ends, and the bowel was brought together and fired. A TA-60 stapler was used to close the enterotomy made across the anastomosis.

Once this was done, the mesenteric defect was closed using a running 3-0 Vicryl suture. At this time, the bowel was placed back into the abdominal wall. The omentum was brought over the small bowel. The liver was lifted once again, and there was no bleeding from the biopsy site. After irrigating out the abdominal cavity, the fascia was closed using a running PDS suture. At this time, the subcutaneous tissue was irrigated and the skin was closed using staples. A dry, sterile dressing was applied. The patient tolerated the procedure without incident and was extubated in the OR and transferred to the recovery room in stable condition.

Dr. XXX  was present for the entire case. The needle, sponge, instrument count were correct at the end of the case.

GASTRIC BYPASS SURGERY

PREOPERATIVE DIAGNOSIS: Class 3 obesity, body mass index equals 39 kg/m2.

POSTOPERATIVE DIAGNOSIS: Class 3 obesity, body mass index equals 39 kg/m2.

OPERATIONS:
1. Roux-en-Y gastric bypass.
2. Esophagogastroduodenoscopy.

ANESTHESIA: General.

INDICATIONS: The patient is a pleasant 42-year-old woman who was referred for a Roux-en-Y gastric bypass, class 3 obesity. Details given of the patient’s long-standing history of weight problems and pattern of repeated failure at weight control, and significance associated with comorbidity were outlined in my preoperative consultation note, which should be read in conjunction with this operative report.

After discussion of clinical diagnosis, management, options, risks and benefits, we elected to proceed with surgery as outlined.

PROCEDURE: Under general anesthesia endotracheal intubation, the patient was prepped and draped in the appropriate manner. We began esophagogastroduodenoscopy. An adult endoscope was easily passed into the esophagus and negotiated through the stomach, down the pylorus and through the duodenum to the second part. Careful endoscopy was performed as the endoscope withdrawn. Mucosa of the first and second parts of the duodenum, mucosa of the gastric antrum body and fundus, as well as the esophageal mucosa were all well within normal limits, with no evidence of inflammatory or neoplastic change. The stomach was desufflated, the endoscope was withdrawn.

The patient was re-prepped and draped for the laparotomy. An upper midline abdominal incision was made through which the abdominal cavity entered and a laparotomy performed. Laparotomy demonstrated some mild fatty infiltration of the liver. Gallbladder was both visually inspected and palpated. There was no evidence of gallstone disease.

At this point, we began with the construction of the Roux-en-Y limb and enteroenterostomy. The transverse colon was reflected cephalad, lateral ligament of Treitz identified, and at a point approximately 40 cm from the ligament of Treitz, the small bowel was transected using a single fire of Endo GIA 3. 5-mm stapler. The distal limb was then measured out to 100 cm corresponding to the patient’s preoperative BMI of 39 kg/m2. An enteroenterostomy was constructed at this point, bringing together the ends of the mesenteric borders of the small bowel in side-to-side fashion. Enterotomies made at each end, it was passed separated limbs with the Endo GIA 3.5 60-mm stapler. The stapler was fired creating a side-to-side anastomosis. This anastomosis was inspected and found to be widely patent and hemostatic and this anastomosis was completed using a single fire of TA-60 3.5 stapler. The mesenteric defect at this site was then closed using a running 3-0 silk suture. The field was copiously lavaged with sterile saline. Satisfactory hemostasis was achieved and we turned our attention to construction of the small gastric pouch.

The triangular ligament at the level of the liver was taken down using electrocautery allowing us to mobilize the left lobe of the liver to the right, thereby exposing the gastroesophageal junction. Peritoneal overlying the anal field was incised using electrocautery. The lesser sac was entered through the gastrocolic omentum also using electrocautery. A small aperture was then made in the lesser omentum immediately adjacent to the lesser curvature of the stomach, approximately 3 cm from the gastroesophageal junction. A ½-inch Penrose drain was threaded between the angle of His and lesser omentum openings. A small antral gastrotomy was made into which was passed the anvil of a CEEA 25 stapler. The post of the anvil was then brought out through a small puncture incision, approximately 2 cm from the gastroesophageal junction. The anvil was anchored into place with a 3-0 silk pursestring suture. The antral gastrotomy was closed using a single fire of TA-60 4.8 stapler. The small gastric pouch was then constructed using multiple firings of the Endo GIA 4.8 stapler. The estimated volume of the small gastric pouch was approximately 30 ml. The field was once again copiously lavaged with sterile saline. Satisfactory hemostasis was achieved.

At this point a small aperture was made in the transverse colon mesentery and the Roux limb was brought proximally in a retro-colonic and retrogastric fashion up to the small gastric pouch. The stapled end of the Roux limb was then reopened using electrocautery, and into this was passed the CEEA 25 stapler. The stapler and anvil were then mated, approximated, and fired creating the gastrojejunal anastomosis. This anastomosis was inspected, found to be widely patent and hemostatic, and this anastomosis was completed using a single fire of the TA-60 3.5 stapler.  Buttressing sutures of 3-0 silk were then placed in a horizontal mattress fashion around the middle creating a gastrojejunal anastomosis.

The Roux-en was then anchored to the transverse colon mesentery, at the point to which it passed, using a 3-0 silk suture.

The remaining mesenteric defect, Peterson’s defect was then closed using 3-0 silk suture. Lastly, the greater curvature of the stomach was inspected, the peritoneum of the anterior abdominal wall, and the left upper quadrant of the abdomen were landmarked with radiopaque clips.

The gastrojejunal anastomosis was leak tested in the usual fashion utilizing 1 L of oxygen by orogastric tube and there was no evidence of anastomosis leak.

The field was once again copiously lavaged with sterile saline. Satisfactory hemostasis was achieved. The midline fascia of the abdomen was closed using a running #2 nylon suture interspersed with interrupted 3-0 and 2-0 nylon sutures. The skin was closed using a running subcuticular 4-0 Monocryl suture. Steri-Strips and a sterile dry dressings were applied.

Estimated blood loss for the procedure approximately 100 mL. The patient tolerated the procedure well. All sponge and instrument counts were correct at the end of the procedure, and the patient came to the recovery room in good condition.