ksb0211
Guest
Just hoping for another opinion on this one. Thanks in advance for any suggestions....
PREOPERATIVE DIAGNOSIS
Gastric volvulus.
POSTOPERATIVE DIAGNOSIS
Gastric volvulus.
OPERATION PERFORMED
Exploratory laparotomy with takedown of adhesions and detorsion of the stomach and gastropexy.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room and after attainment of sufficient general anesthesia she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. Made a midline incision, opened the abdominal cavity, and we could see that the stomach was torqued, and actually not quite cyanotic, but you could see it was impaired, held the stomach and it was just very turgid and Dr. XXXXX was unable to get an NG tube into the stomach just by gently trying to pass. Looking at the stomach we could see she had had a previous PEG tube, probably as a result of her previous neurologic injury, and that is a surmise on my part, but the PEG tube site, the site was on the left side of the abdomen but the actual entry point for the PEG tube was over distal down toward the antrum actually near the pylorus. So what the PEG tube had in effect done was torque the stomach up into the kind of the left upper quadrant into the beginnings of this volvulus, and it had volvulized around that point. So what I did was I took down the PEG tube site staying on the abdominal wall side. That released the stomach. Once that was done I could pull the stomach down. We easily got that NG tube in, decompressed the stomach and took out, probably taking out 2 liters of inspissated coffee-grounds looking material. Stomach was good. It pinked up immediately. We fixed the PEG tube site. There was really no entry into the stomach and there was no spillage in the operative field. Once we got the stomach decompressed it was a pretty easy operation from the looks of it. The stomach was flaccid. We fixed the body of the stomach on the left side up to the anterior abdominal wall with three relatively widely spaced sutures of 2-0 silk and then placed a gastrostomy tube into the antrum on the right side of her abdomen, though we did not put the PEG tube on the left side because of the presence of a colostomy bag that is right in that same site. So we placed the PEG tube, actually it was a G-tube, went through the abdominal wall, and how we did that was we took a cannula from a laparoscopy and ran it from the abdomen out and then put the PEG tube, sort of got the nose of it into that cannula and then pushed it back through and were able to get the tube in to the stomach that way, and put 2 pursestring sutures into the stomach, made a Bovie access into the stomach, and then put the tube in, insufflated to 10 mL, brought it up against the abdominal wall, tightened down the pursestrings, then fixed those two 2-0 silks into the stomach, giving us now 2 fixation points, one in the left side, there are 3 sutures of 2-0 silk, and now on the right side over by the antrum the G-tube. We then irrigated and aspirated, closed with double stranded #1 PDS, followed by irrigation, followed by skin staples. We injected with Marcaine at the end of the procedure. She tolerated the procedure well.
PREOPERATIVE DIAGNOSIS
Gastric volvulus.
POSTOPERATIVE DIAGNOSIS
Gastric volvulus.
OPERATION PERFORMED
Exploratory laparotomy with takedown of adhesions and detorsion of the stomach and gastropexy.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room and after attainment of sufficient general anesthesia she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. Made a midline incision, opened the abdominal cavity, and we could see that the stomach was torqued, and actually not quite cyanotic, but you could see it was impaired, held the stomach and it was just very turgid and Dr. XXXXX was unable to get an NG tube into the stomach just by gently trying to pass. Looking at the stomach we could see she had had a previous PEG tube, probably as a result of her previous neurologic injury, and that is a surmise on my part, but the PEG tube site, the site was on the left side of the abdomen but the actual entry point for the PEG tube was over distal down toward the antrum actually near the pylorus. So what the PEG tube had in effect done was torque the stomach up into the kind of the left upper quadrant into the beginnings of this volvulus, and it had volvulized around that point. So what I did was I took down the PEG tube site staying on the abdominal wall side. That released the stomach. Once that was done I could pull the stomach down. We easily got that NG tube in, decompressed the stomach and took out, probably taking out 2 liters of inspissated coffee-grounds looking material. Stomach was good. It pinked up immediately. We fixed the PEG tube site. There was really no entry into the stomach and there was no spillage in the operative field. Once we got the stomach decompressed it was a pretty easy operation from the looks of it. The stomach was flaccid. We fixed the body of the stomach on the left side up to the anterior abdominal wall with three relatively widely spaced sutures of 2-0 silk and then placed a gastrostomy tube into the antrum on the right side of her abdomen, though we did not put the PEG tube on the left side because of the presence of a colostomy bag that is right in that same site. So we placed the PEG tube, actually it was a G-tube, went through the abdominal wall, and how we did that was we took a cannula from a laparoscopy and ran it from the abdomen out and then put the PEG tube, sort of got the nose of it into that cannula and then pushed it back through and were able to get the tube in to the stomach that way, and put 2 pursestring sutures into the stomach, made a Bovie access into the stomach, and then put the tube in, insufflated to 10 mL, brought it up against the abdominal wall, tightened down the pursestrings, then fixed those two 2-0 silks into the stomach, giving us now 2 fixation points, one in the left side, there are 3 sutures of 2-0 silk, and now on the right side over by the antrum the G-tube. We then irrigated and aspirated, closed with double stranded #1 PDS, followed by irrigation, followed by skin staples. We injected with Marcaine at the end of the procedure. She tolerated the procedure well.