bda23054
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NAME OF OPERATION
Exploratory laparotomy.
Pyloroplasty with suture ligation of bleeding ulcer.
Intraoperative endoscopy.
Conversion of gastrostomy to feeding jejunostomy.
JP-drain placement.
INDICATIONS
This is a 65-year-old male who has had a long, drawn out medical history, especially in the year of 2012 he had had a massive heart attack and complications following an angioplasty. He then developed renal failure and on this admission was admitted for rectal bleeding. Dr. Byrne had done a pre-procedure endoscopy and found a large bleeding duodenal ulcer. He said he was unable to control the bleeding during endoscopy. The patient required 6 units of blood and was hemodynamically unstable.
DESCRIPTION OF OPERATION
The patient was rushed into the Operating Room, placed in the supine position. The patient had a previous tracheostomy, which was used for general anesthesia. Preoperative antibiotics were given. Foley catheters were placed and a nasogastric tube was placed. The abdomen was prepped and draped in the usual sterile fashion.
A vertical skin incision was made from the xiphoid to just above the umbilicus. This was deepened through subcutaneous tissues and hemostasis was achieved with electrocautery. The linea alba was identified and incised and the peritoneal cavity was entered. The abdomen was explored. There were noted to be dense adhesions between the previous gallbladder surgery and duodenum. After kocherization of the duodenum, thankfully Dr. Byrne had placed India ink to the bleeding area and two silk stay sutures of 2-0 were placed on the duodenum. There was noted to be a posterior ulceration with active bleeding on the second portion of the duodenum. Hemostasis was achieved with three sutures of 2-0 silk placed to control the bleeding. All clot was suctioned and the duodenum was packed lightly. At this point intraoperative endoscopy was performed going distally on the duodenum as far distally has possible. There was noted to be no other active bleeding. Several of Dr. Byrne's clips were identified. I spoke to Dr. Byrne intraoperatively, he said the clips were part of the reason the bleeding was not controlled, the clips did not stay in place and so these were not sources of bleeding. Attention was then turned proximally to the pylorus. There were noted to be no other sources of bleeding. Once this was done attention was then turned to the previously placed PEG, which was converted into a feeding jejunostomy. A guidewire was placed through the PEG, the PEG was then removed through the duodenostomy that was created to control the bleeding. The guidewire was placed distal in the jejunum and then using a 16-French feeding jejunostomy tube this was placed through the gastrostomy site and into the distal jejunum. Once this was controlled and fixated in place it was easily flushed without any difficulty attention was turned to the duodenostomy that was made. Using 2-0 silk sutures the duodenostomy was closed transversely, on the first layer through the serosal mucosa taking deep bites and then oversewing the closure with another layer of 2-0 silk sutures. Once this was completed hemostasis was again controlled and a separate stab wound incision brought out through the right lateral quadrant was used to place a 19-Blake drain. This was placed at the area of the anastomosis at the closure, and a third layer of 2-0 silk sutures were used to do a duodenal patch bringing a layer of omentum between the closure and omentum and suturing with 2-0 silk sutures. Once this was closed the drain was placed and the abdomen was then irrigated with approximately 5 liters normal saline and suctioned out. The nasogastric tube was placed by anesthesia and confirmed proper placement in the gastric unit by direct palpation. The wound was then closed in layers with an 0-PDS suture for the peritoneal fascial layers and then skin staples for the skin layer. Provena wound V.A.C. was placed.
Exploratory laparotomy.
Pyloroplasty with suture ligation of bleeding ulcer.
Intraoperative endoscopy.
Conversion of gastrostomy to feeding jejunostomy.
JP-drain placement.
INDICATIONS
This is a 65-year-old male who has had a long, drawn out medical history, especially in the year of 2012 he had had a massive heart attack and complications following an angioplasty. He then developed renal failure and on this admission was admitted for rectal bleeding. Dr. Byrne had done a pre-procedure endoscopy and found a large bleeding duodenal ulcer. He said he was unable to control the bleeding during endoscopy. The patient required 6 units of blood and was hemodynamically unstable.
DESCRIPTION OF OPERATION
The patient was rushed into the Operating Room, placed in the supine position. The patient had a previous tracheostomy, which was used for general anesthesia. Preoperative antibiotics were given. Foley catheters were placed and a nasogastric tube was placed. The abdomen was prepped and draped in the usual sterile fashion.
A vertical skin incision was made from the xiphoid to just above the umbilicus. This was deepened through subcutaneous tissues and hemostasis was achieved with electrocautery. The linea alba was identified and incised and the peritoneal cavity was entered. The abdomen was explored. There were noted to be dense adhesions between the previous gallbladder surgery and duodenum. After kocherization of the duodenum, thankfully Dr. Byrne had placed India ink to the bleeding area and two silk stay sutures of 2-0 were placed on the duodenum. There was noted to be a posterior ulceration with active bleeding on the second portion of the duodenum. Hemostasis was achieved with three sutures of 2-0 silk placed to control the bleeding. All clot was suctioned and the duodenum was packed lightly. At this point intraoperative endoscopy was performed going distally on the duodenum as far distally has possible. There was noted to be no other active bleeding. Several of Dr. Byrne's clips were identified. I spoke to Dr. Byrne intraoperatively, he said the clips were part of the reason the bleeding was not controlled, the clips did not stay in place and so these were not sources of bleeding. Attention was then turned proximally to the pylorus. There were noted to be no other sources of bleeding. Once this was done attention was then turned to the previously placed PEG, which was converted into a feeding jejunostomy. A guidewire was placed through the PEG, the PEG was then removed through the duodenostomy that was created to control the bleeding. The guidewire was placed distal in the jejunum and then using a 16-French feeding jejunostomy tube this was placed through the gastrostomy site and into the distal jejunum. Once this was controlled and fixated in place it was easily flushed without any difficulty attention was turned to the duodenostomy that was made. Using 2-0 silk sutures the duodenostomy was closed transversely, on the first layer through the serosal mucosa taking deep bites and then oversewing the closure with another layer of 2-0 silk sutures. Once this was completed hemostasis was again controlled and a separate stab wound incision brought out through the right lateral quadrant was used to place a 19-Blake drain. This was placed at the area of the anastomosis at the closure, and a third layer of 2-0 silk sutures were used to do a duodenal patch bringing a layer of omentum between the closure and omentum and suturing with 2-0 silk sutures. Once this was closed the drain was placed and the abdomen was then irrigated with approximately 5 liters normal saline and suctioned out. The nasogastric tube was placed by anesthesia and confirmed proper placement in the gastric unit by direct palpation. The wound was then closed in layers with an 0-PDS suture for the peritoneal fascial layers and then skin staples for the skin layer. Provena wound V.A.C. was placed.