slc112071
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I have the following report that our bariatrics surgeons performed that turned into a gastric surgery. Could someone please help?????
PREOPERATIVE DIAGNOSES:
1. Morbid obesity.
2. Hypertension.
3. Hyperlipidemia.
4. History of Cushing's syndrome, status post resection of pituitary adenoma.
POSTOPERATIVE DIAGNOSES:
1. Multiple submucosal gastric masses.
2. Morbid obesity.
3. Hypertension.
4. Hyperlipidemia.
5. History of Cushing syndrome.
PROCEDURES:
1. Diagnostic laparoscopy.
2. Laparoscopic partial gastrectomy.
3. Laparoscopic lymph node biopsy.
4. Intraoperative EGD by Dr. H.
ANESTHESIA: General endotracheal anesthesia.
FLUIDS: Please see anesthesia notes.
ESTIMATED BLOOD LOSS: Less than 30 mL
COMPLICATIONS: None apparent.
COUNTS: Sponge and needle counts were reported as correct x 2 at the
completion of the procedure.
SUMMARY OF PROCEDURE: The patient was seen in the preoperative area and
planned procedure was confirmed with her and her husband. I discussed risks,
benefits and options of the procedure with her and her husband once again.
They seemed to understand and she wished to proceed. After informed consent,
she was taken to the operating room where she was placed in supine position.
After adequate general endotracheal anesthesia was achieved, a time-out was
held. The patient and planned procedure were confirmed. The patient was
given IV Ancef preoperatively and positioned. After this, her lower chest and
abdomen were prepped and draped in usual sterile fashion. A 5 mm optical
viewing trocar was placed through a left upper quadrant incision and the
abdominal wall was traversed under visualization, the peritoneal cavity
entered without difficulty. The peritoneal cavity was insufflated with CO2
and a laparoscope was inserted. Laparoscopy revealed a normal appearing liver
and visible small bowel and colon. No obvious abnormalities were identified
initially. After this, additional trocars were placed under direct
laparoscopic visualization without difficulty. The patient was then placed
into a reversed Trendelenburg position and a liver retractor was placed,
retracting the left lobe of the liver anteriorly and medially. After doing
so, the stomach was inspected and it became apparent that there appeared to be
a small approximately 2 cm mass present in the anterior wall of the stomach in
the mid body of the stomach. Inspection of the GE junction revealed some
prominence in the retrogastric region as well. Inspection of the antrum and
pylorus revealed what appeared to be at least two additional masses in the
gastric wall at the pylorus, one inferior and one superior to the pylorus.
The first portion of the duodenum appeared normal, the liver was inspected
more thoroughly and appeared completely normal with no evidence of hepatic
masses. The gallbladder appeared normal. At this point did this, decision
was made to incise the pars flaccida to evaluate the posterior gastric area.
The pars flaccida was then incised with electrocautery without difficulty.
The pancreas was then inspected. The pancreas was noted to be somewhat
prominent, but the patient did not really did not have a lot of perigastric
fat despite her morbid obesity. There appeared to be a small lymph node along
the left gastric arcade. This was excised using Harmonic scalpel and handed
off to Dr. F and he confirmed that this was a lymph node, but on frozen
section, it appeared benign. Based on the findings of the gastric masses, it
was felt that the patient would need an EGD. We therefore had asked Dr. H to
come during the procedure to perform this as it was felt that if a gastric
mass could be confirmed it might be possible to biopsy during this procedure.
Dr. H came in and performed EGD and this confirmed at least 2-3 submucosal
mass, the largest of which was the one visualized in the mid body of the
stomach anteriorly. There also appeared to be at least 1-2 smaller submucosal
this submucosal mass is in the antrum. She was able to visualize the pylorus
as well the first portion of the duodenum. We were not able to identify any
clear submucosal masses in the area of the pylorus or duodenum, but there was
clearly no evidence of mucosal disease. Based on the findings, it was felt
that the best option would be to resect the mass seen in the anterior wall of
the stomach for pathologic diagnosis. It was suspected that these lesions
were either leiomyomas or gist tumor. It was felt that we would be able to
wedge out the mass in the anterior stomach for a tissue diagnosis. It was
also felt that it would be best not to proceed with the lap-band procedure at
this time and await the pathology and further evaluation postoperatively. Dr.
H and Dr. CF as well as Dr. F were all in agreement with this.
Actually Dr. T came into the room during the procedure and was also in
agreement with that plan. After this, the EGD scope was removed. The mass in
the anterior gastric wall was able to be elevated and it was clear based on
gas left in the stomach that this was just the anterior wall. I was able to
place a GIA stapler below the mass with a blue load and fire it x 2 resecting
the mass. The mass was placed into an Endobag and removed through the 15 mm
trocar site and handed off to Dr. F. The staple line was then inspected.
There was a little bit of oozing from several areas along the staple line and
this was controlled with Hemoclips. The staple line wound was noted to be an
intact throughout. Pictures of each of these areas were obtained for
documentation. After observing this staple line for at least 5-10 minutes.
It was apparent that there was good hemostasis now along the staple line.
Again, the staple line appeared to be nice and intact. No complications were
evident. Decision was therefore made to stop the procedure and to proceed
with further evaluation and await pathology postoperatively. The abdomen was
therefore deflated and all instruments and trocars were removed. Each
incision was infiltrated with 0.5% Marcaine with epinephrine. Skin incisions
were reapproximated with 3-0 plain gut subcuticular sutures and Steri-Strips.
Sterile dressings were applied. The patient tolerated the procedure well and
was awakened and transported recovery room in stable condition.
PREOPERATIVE DIAGNOSES:
1. Morbid obesity.
2. Hypertension.
3. Hyperlipidemia.
4. History of Cushing's syndrome, status post resection of pituitary adenoma.
POSTOPERATIVE DIAGNOSES:
1. Multiple submucosal gastric masses.
2. Morbid obesity.
3. Hypertension.
4. Hyperlipidemia.
5. History of Cushing syndrome.
PROCEDURES:
1. Diagnostic laparoscopy.
2. Laparoscopic partial gastrectomy.
3. Laparoscopic lymph node biopsy.
4. Intraoperative EGD by Dr. H.
ANESTHESIA: General endotracheal anesthesia.
FLUIDS: Please see anesthesia notes.
ESTIMATED BLOOD LOSS: Less than 30 mL
COMPLICATIONS: None apparent.
COUNTS: Sponge and needle counts were reported as correct x 2 at the
completion of the procedure.
SUMMARY OF PROCEDURE: The patient was seen in the preoperative area and
planned procedure was confirmed with her and her husband. I discussed risks,
benefits and options of the procedure with her and her husband once again.
They seemed to understand and she wished to proceed. After informed consent,
she was taken to the operating room where she was placed in supine position.
After adequate general endotracheal anesthesia was achieved, a time-out was
held. The patient and planned procedure were confirmed. The patient was
given IV Ancef preoperatively and positioned. After this, her lower chest and
abdomen were prepped and draped in usual sterile fashion. A 5 mm optical
viewing trocar was placed through a left upper quadrant incision and the
abdominal wall was traversed under visualization, the peritoneal cavity
entered without difficulty. The peritoneal cavity was insufflated with CO2
and a laparoscope was inserted. Laparoscopy revealed a normal appearing liver
and visible small bowel and colon. No obvious abnormalities were identified
initially. After this, additional trocars were placed under direct
laparoscopic visualization without difficulty. The patient was then placed
into a reversed Trendelenburg position and a liver retractor was placed,
retracting the left lobe of the liver anteriorly and medially. After doing
so, the stomach was inspected and it became apparent that there appeared to be
a small approximately 2 cm mass present in the anterior wall of the stomach in
the mid body of the stomach. Inspection of the GE junction revealed some
prominence in the retrogastric region as well. Inspection of the antrum and
pylorus revealed what appeared to be at least two additional masses in the
gastric wall at the pylorus, one inferior and one superior to the pylorus.
The first portion of the duodenum appeared normal, the liver was inspected
more thoroughly and appeared completely normal with no evidence of hepatic
masses. The gallbladder appeared normal. At this point did this, decision
was made to incise the pars flaccida to evaluate the posterior gastric area.
The pars flaccida was then incised with electrocautery without difficulty.
The pancreas was then inspected. The pancreas was noted to be somewhat
prominent, but the patient did not really did not have a lot of perigastric
fat despite her morbid obesity. There appeared to be a small lymph node along
the left gastric arcade. This was excised using Harmonic scalpel and handed
off to Dr. F and he confirmed that this was a lymph node, but on frozen
section, it appeared benign. Based on the findings of the gastric masses, it
was felt that the patient would need an EGD. We therefore had asked Dr. H to
come during the procedure to perform this as it was felt that if a gastric
mass could be confirmed it might be possible to biopsy during this procedure.
Dr. H came in and performed EGD and this confirmed at least 2-3 submucosal
mass, the largest of which was the one visualized in the mid body of the
stomach anteriorly. There also appeared to be at least 1-2 smaller submucosal
this submucosal mass is in the antrum. She was able to visualize the pylorus
as well the first portion of the duodenum. We were not able to identify any
clear submucosal masses in the area of the pylorus or duodenum, but there was
clearly no evidence of mucosal disease. Based on the findings, it was felt
that the best option would be to resect the mass seen in the anterior wall of
the stomach for pathologic diagnosis. It was suspected that these lesions
were either leiomyomas or gist tumor. It was felt that we would be able to
wedge out the mass in the anterior stomach for a tissue diagnosis. It was
also felt that it would be best not to proceed with the lap-band procedure at
this time and await the pathology and further evaluation postoperatively. Dr.
H and Dr. CF as well as Dr. F were all in agreement with this.
Actually Dr. T came into the room during the procedure and was also in
agreement with that plan. After this, the EGD scope was removed. The mass in
the anterior gastric wall was able to be elevated and it was clear based on
gas left in the stomach that this was just the anterior wall. I was able to
place a GIA stapler below the mass with a blue load and fire it x 2 resecting
the mass. The mass was placed into an Endobag and removed through the 15 mm
trocar site and handed off to Dr. F. The staple line was then inspected.
There was a little bit of oozing from several areas along the staple line and
this was controlled with Hemoclips. The staple line wound was noted to be an
intact throughout. Pictures of each of these areas were obtained for
documentation. After observing this staple line for at least 5-10 minutes.
It was apparent that there was good hemostasis now along the staple line.
Again, the staple line appeared to be nice and intact. No complications were
evident. Decision was therefore made to stop the procedure and to proceed
with further evaluation and await pathology postoperatively. The abdomen was
therefore deflated and all instruments and trocars were removed. Each
incision was infiltrated with 0.5% Marcaine with epinephrine. Skin incisions
were reapproximated with 3-0 plain gut subcuticular sutures and Steri-Strips.
Sterile dressings were applied. The patient tolerated the procedure well and
was awakened and transported recovery room in stable condition.