natalieworkman@att.net
Contributor
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed in supine position. Standard monitors were applied. Endotracheal intubation was achieved and general anesthetic was administered. A perioperative time-out was performed, which confirmed the identity of the patient as well as the procedure to be performed. All present were in agreement. A bronchial blocker was placed on the right side by our Anesthesia colleagues. We then repositioned the patient in a lazy left lateral decubitus position. We prepped and draped in standard surgical fashion. Perioperative antibiotics were administered. We began by marking out the scapular tip and placing a 5 mm trocar just below this into the chest. A 5-mm 45-degree thoracoscope was inserted into the chest and immediately a large amount of bowel was present. We then insufflated the chest to 8 mmHg of carbon dioxide and the working room improved. The lungs were nicely atelectatic giving us more room to work. We then placed 2 additional trocars anterior to this; each was 5 mm. We then began the process of reducing the bowel through what appeared to be a small posterolateral hernia. The lip of the hernia was grasped and lifted anteriorly and the bowel was sequentially reduced into the abdominal cavity. The mesentery was flat. There did not seem to be any twisting of the bowel, was returned to the abdomen. It should be noted that upon reduction of the bowel into the abdomen, we noted a wide-based Meckel's diverticulum with no obvious thickness to the tip. We elected not to turn a clean case to a clean contaminated case by resecting this Meckel's, and as such, returned it to the abdominal cavity. Once the entirety of the bowel had been reduced, we were able to elucidate the perimeter of the hernia defect. It was very small. There was no sac around any of the bowel when we got into the chest. There was, however, a small portion of the sac covering half of the hernia defect underneath the musculature itself. We opted to leave this alone and began closing the defect. We passed the suture through stab incisions to the lateral abdominal wall, pledgeted these intracorporeally. These were all 2-0 Prolene sutures. We created U-stitches through the meet of the muscular wall of the diaphragmatic hernia and passed these back to the chest wall with a suture passer. We performed this 3 times and the hernia defect was closed around the rib with each stitch. There was no tension on the diaphragmatic repair and we examined the underside of it and found there to be no possible way for the hernia to reoccur
Through any persistent defect. Satisfied with our closure, we suctioned out the chest with a small amount of serous fluid present. We then placed a suction catheter in the chest and removed as much capnothorax as was feasible while recruitment breaths were given by our Anesthesia colleagues. The suction catheter was removed from the chest after being placed under water-seal and creation of air bubbles ceased. We then turned our attention to closure. Each 5 mm trocar site was closed in 3 layers with a 3-0 Vicryl in the musculature in an interrupted fashion, followed by 4-0 Vicryl in the deep dermal tissue, followed by 5-0 Monocryl in the subcuticular fashion. Dermabond was applied to each of the wounds. Dermabond was also applied to the stab incisions on the lateral chest wall.
At this point, it should be noted that we did allow our Anesthesia colleagues to reinsufflate the lung after removing the bronchial blocker under direct visualization. There was good inflation of the lung.
At this point, we turned the patient over to Anesthesia and he was awakened without difficulty. He was transferred to PACU in stable condition. All lap, instrument, and needle counts were correct at the end of the case.
The patient was brought to the operating room and placed in supine position. Standard monitors were applied. Endotracheal intubation was achieved and general anesthetic was administered. A perioperative time-out was performed, which confirmed the identity of the patient as well as the procedure to be performed. All present were in agreement. A bronchial blocker was placed on the right side by our Anesthesia colleagues. We then repositioned the patient in a lazy left lateral decubitus position. We prepped and draped in standard surgical fashion. Perioperative antibiotics were administered. We began by marking out the scapular tip and placing a 5 mm trocar just below this into the chest. A 5-mm 45-degree thoracoscope was inserted into the chest and immediately a large amount of bowel was present. We then insufflated the chest to 8 mmHg of carbon dioxide and the working room improved. The lungs were nicely atelectatic giving us more room to work. We then placed 2 additional trocars anterior to this; each was 5 mm. We then began the process of reducing the bowel through what appeared to be a small posterolateral hernia. The lip of the hernia was grasped and lifted anteriorly and the bowel was sequentially reduced into the abdominal cavity. The mesentery was flat. There did not seem to be any twisting of the bowel, was returned to the abdomen. It should be noted that upon reduction of the bowel into the abdomen, we noted a wide-based Meckel's diverticulum with no obvious thickness to the tip. We elected not to turn a clean case to a clean contaminated case by resecting this Meckel's, and as such, returned it to the abdominal cavity. Once the entirety of the bowel had been reduced, we were able to elucidate the perimeter of the hernia defect. It was very small. There was no sac around any of the bowel when we got into the chest. There was, however, a small portion of the sac covering half of the hernia defect underneath the musculature itself. We opted to leave this alone and began closing the defect. We passed the suture through stab incisions to the lateral abdominal wall, pledgeted these intracorporeally. These were all 2-0 Prolene sutures. We created U-stitches through the meet of the muscular wall of the diaphragmatic hernia and passed these back to the chest wall with a suture passer. We performed this 3 times and the hernia defect was closed around the rib with each stitch. There was no tension on the diaphragmatic repair and we examined the underside of it and found there to be no possible way for the hernia to reoccur
Through any persistent defect. Satisfied with our closure, we suctioned out the chest with a small amount of serous fluid present. We then placed a suction catheter in the chest and removed as much capnothorax as was feasible while recruitment breaths were given by our Anesthesia colleagues. The suction catheter was removed from the chest after being placed under water-seal and creation of air bubbles ceased. We then turned our attention to closure. Each 5 mm trocar site was closed in 3 layers with a 3-0 Vicryl in the musculature in an interrupted fashion, followed by 4-0 Vicryl in the deep dermal tissue, followed by 5-0 Monocryl in the subcuticular fashion. Dermabond was applied to each of the wounds. Dermabond was also applied to the stab incisions on the lateral chest wall.
At this point, it should be noted that we did allow our Anesthesia colleagues to reinsufflate the lung after removing the bronchial blocker under direct visualization. There was good inflation of the lung.
At this point, we turned the patient over to Anesthesia and he was awakened without difficulty. He was transferred to PACU in stable condition. All lap, instrument, and needle counts were correct at the end of the case.