afryberger
Networker
For the following OP report I got 47780,47600 and 38747. I am not sure if this is correct or if I am missing anything. 47711???
Patient was brought to the operating room on 02/08/2013 and placed in supine
position. After induction of general endotracheal anesthesia, a central venous
catheter was placed in the left internal jugular vein and arterial line was placed
and a Foley catheter was inserted. An epidural catheter postop analgesia was also
placed. The abdomen was prepped and draped in the usual sterile fashion. A
midline incision was made starting from the xiphoid in the midline and extended
towards the umbilicus in the midline and was curved around the umbilicus or
another inch in the midline below the umbilicus and carried down to subcutaneous
tissue. Further dissection was carried out with help of cautery and the abdominal
wall fascia was opened in the midline all along the length of the skin incision.
Once the abdominal cavity was entered. The falciform ligament was divided between
clamps and was suture ligated and then exploratory laparotomy was performed
including in the entire peritoneal surface and the liver was inspected without any
evidence of any metastasis and then the stomach, the small intestine all the way
from the ligament of Treitz to the ileocecal valve and then the entire large
intestine from the ileocecal valve all the way to the rectum was inspected and
found to be within normal limits. No signs of any disseminated disease. At this
point, we proceeded with Kocher maneuver and we kocherized the head of the
pancreas with the 2nd part of the duodenum all the way to the point where we could
see the aorta and we did not feel any significant mass in the head of the
pancreas. At this point, we decided to proceed signed procedure. The plan was to
proceed with hilar or periportal lymphadenectomy starting from the superior aspect
of the head of the pancreas and to continue through the gallbladder and then take
the cystic duct and sent the cystic duct stump for frozen section and take the
gallbladder along with the en bloc periportal lymphadenectomy and 2 cm piece of
segment 4B and 5 of the liver. So, the procedure was started as planned. We took
the lymph nodes, starting from the supraduodenal area and we proceeded superiorly.
We did a lymphadenectomy around the common hepatic artery and follow it towards
the branches of the common hepatic artery and proper hepatic artery and all the
lymph node was taken in 1 piece and then once we get to the area of the cystic
duct, we realized that there was no cystic duct and the gallbladder body was
completely plastered against the common hepatic duct and there was no room between
the liver, surface, segment 4B, inferior surface of the segment 4B. The body of
the gallbladder and the common hepatic duct. Therefore, we decided to not come
from the fundus towards the cystic duct but there was a problem that if we take
the liver with it the segment 4B and 5. Then, we will end up in the middle of the
liver without any guidance. Therefore, at this time, we decided that we have to
take the common hepatic duct, because it looks like the mass was invading into the
common hepatic duct and to do that we dissected the common bile duct at the upper
border of the 1st part of the duodenum and dissected free from the underlying
portal vein and then we suture ligated the distal part of the common bile duct in
the head of the pancreas using 3-0 silk suture and then we lifted the entire
common bile duct cephalad. Taking all the lymph nodes around the anterior to the
portal vein all the way up to the region of the cystic duct and the common hepatic
duct and once we went behind the common hepatic duct. We had no option but to
bring the gallbladder down without the piece of the segment 4B and 5 and once we
did that, we could go around the common hepatic at this point, which was divided.
At this time, we had the specimen which contained the perihilar lymph nodes and
the common bile duct and the common hepatic duct and the gallbladder attached to
it with the mass inside it. The entire specimen was sent to pathology for frozen
section before the distal margin of the common bile duct and the margin of the
common hepatic duct proximally and the gallbladder itself. Once the patient was
taken out, we could see the left and right hepatic ducts joining and also you
could see the coated branch coming into the left hepatic duct and a small branch
coming from the segment 4B. Once at this time, we decided that we should go ahead
and take the margin of the segment 4B and 5 again this was a cancer of the
gallbladder but once the frozen section came back it showed negative margin on the
common hepatic duct side and negative margin on the common bile duct side and
incised the liver. The mucosa was smooth and according to the initial assessment
it was less likely to harbor a carcinoma. At this point, we debated that should
we go ahead and resect the liver but since we do not have much evidence, we
decided not to resect the liver and we proceeded with reconstruction. We did have
a small lining of the liver along the gallbladder but we did not have a formal
liver resection. We created a Roux-en-Y limb, 30 cm from the ligament of Treitz
and then we did a jejunojejunostomy using an Endo-GIA blue load which is 3.8, 80-
mm long and then we fired by directionally and then closed the enterotomy site
using another load of 3.8, 60 mm long stapler and then all the stapled lines were
reinforced with multiple interrupted seromuscular 3-0 silk sutures. The defect in
the mesentery was closed by using continuous running suture of 3-0 Vicryl. So
that, there is no chance for future hernia through this defect and then we used
the Roux limb to bring it out through the infracolic compartment to the right side
of the middle colic artery into the right upper quadrant and then made
hepaticojejunostomy. We placed the Roux limb next to the common hepatic duct and
then we made a small enterotomy on the antimesenteric border measuring about 1 cm.
First, we made the posterior layer by using interrupted 4-0 PDS sutures, duct,
mucosa, and with the knots inside and then we put the anteriorly, similarly
interrupted suture of 4-0 PDS with the knots outside. After finishing the entire
anastomosis, we closed the defect in the mesocolon through which we brought the
Roux limb around the Roux limb itself using 3-0 silk interrupted sutures so that
there is no herniation and then it was noted that there was no tension on the
anastomosis. Anastomosis was pretty much watertight and then we again reexplored
the abdominal cavity just to make sure we ran the bowel again which seemed to be
well oriented without any signs of obstruction. The large bowel was also within
normal limits. Stomach was normal and then hepaticojejunostomy site was also
intact. We placed a drain through the right upper quadrant, a 19-French drain and
was placed behind the hepaticojejunostomy and secured to the skin using nylon
suture. The abdominal cavity was thoroughly irrigated, suction dried. During the
dissection of the common bile duct, lifting off the portal vein, we had at 1
point, a small tributary of the portal vein blood maybe 20 to 30 cc which was
controlled with a figure-of-eight 5-0 Prolene suture. At the end, the abdominal
wall was closed . At that time, I have left the
procedure. I performed this procedure as a co-surgeon and at
the end of the procedure, all the counts were correct. The total blood loss was
around 200 to 300 cc and the patient tolerated the procedure very well and was not
extubated and was transferred in the ICU while intubated with the plan that
patient will be extubated in the morning.
Patient was brought to the operating room on 02/08/2013 and placed in supine
position. After induction of general endotracheal anesthesia, a central venous
catheter was placed in the left internal jugular vein and arterial line was placed
and a Foley catheter was inserted. An epidural catheter postop analgesia was also
placed. The abdomen was prepped and draped in the usual sterile fashion. A
midline incision was made starting from the xiphoid in the midline and extended
towards the umbilicus in the midline and was curved around the umbilicus or
another inch in the midline below the umbilicus and carried down to subcutaneous
tissue. Further dissection was carried out with help of cautery and the abdominal
wall fascia was opened in the midline all along the length of the skin incision.
Once the abdominal cavity was entered. The falciform ligament was divided between
clamps and was suture ligated and then exploratory laparotomy was performed
including in the entire peritoneal surface and the liver was inspected without any
evidence of any metastasis and then the stomach, the small intestine all the way
from the ligament of Treitz to the ileocecal valve and then the entire large
intestine from the ileocecal valve all the way to the rectum was inspected and
found to be within normal limits. No signs of any disseminated disease. At this
point, we proceeded with Kocher maneuver and we kocherized the head of the
pancreas with the 2nd part of the duodenum all the way to the point where we could
see the aorta and we did not feel any significant mass in the head of the
pancreas. At this point, we decided to proceed signed procedure. The plan was to
proceed with hilar or periportal lymphadenectomy starting from the superior aspect
of the head of the pancreas and to continue through the gallbladder and then take
the cystic duct and sent the cystic duct stump for frozen section and take the
gallbladder along with the en bloc periportal lymphadenectomy and 2 cm piece of
segment 4B and 5 of the liver. So, the procedure was started as planned. We took
the lymph nodes, starting from the supraduodenal area and we proceeded superiorly.
We did a lymphadenectomy around the common hepatic artery and follow it towards
the branches of the common hepatic artery and proper hepatic artery and all the
lymph node was taken in 1 piece and then once we get to the area of the cystic
duct, we realized that there was no cystic duct and the gallbladder body was
completely plastered against the common hepatic duct and there was no room between
the liver, surface, segment 4B, inferior surface of the segment 4B. The body of
the gallbladder and the common hepatic duct. Therefore, we decided to not come
from the fundus towards the cystic duct but there was a problem that if we take
the liver with it the segment 4B and 5. Then, we will end up in the middle of the
liver without any guidance. Therefore, at this time, we decided that we have to
take the common hepatic duct, because it looks like the mass was invading into the
common hepatic duct and to do that we dissected the common bile duct at the upper
border of the 1st part of the duodenum and dissected free from the underlying
portal vein and then we suture ligated the distal part of the common bile duct in
the head of the pancreas using 3-0 silk suture and then we lifted the entire
common bile duct cephalad. Taking all the lymph nodes around the anterior to the
portal vein all the way up to the region of the cystic duct and the common hepatic
duct and once we went behind the common hepatic duct. We had no option but to
bring the gallbladder down without the piece of the segment 4B and 5 and once we
did that, we could go around the common hepatic at this point, which was divided.
At this time, we had the specimen which contained the perihilar lymph nodes and
the common bile duct and the common hepatic duct and the gallbladder attached to
it with the mass inside it. The entire specimen was sent to pathology for frozen
section before the distal margin of the common bile duct and the margin of the
common hepatic duct proximally and the gallbladder itself. Once the patient was
taken out, we could see the left and right hepatic ducts joining and also you
could see the coated branch coming into the left hepatic duct and a small branch
coming from the segment 4B. Once at this time, we decided that we should go ahead
and take the margin of the segment 4B and 5 again this was a cancer of the
gallbladder but once the frozen section came back it showed negative margin on the
common hepatic duct side and negative margin on the common bile duct side and
incised the liver. The mucosa was smooth and according to the initial assessment
it was less likely to harbor a carcinoma. At this point, we debated that should
we go ahead and resect the liver but since we do not have much evidence, we
decided not to resect the liver and we proceeded with reconstruction. We did have
a small lining of the liver along the gallbladder but we did not have a formal
liver resection. We created a Roux-en-Y limb, 30 cm from the ligament of Treitz
and then we did a jejunojejunostomy using an Endo-GIA blue load which is 3.8, 80-
mm long and then we fired by directionally and then closed the enterotomy site
using another load of 3.8, 60 mm long stapler and then all the stapled lines were
reinforced with multiple interrupted seromuscular 3-0 silk sutures. The defect in
the mesentery was closed by using continuous running suture of 3-0 Vicryl. So
that, there is no chance for future hernia through this defect and then we used
the Roux limb to bring it out through the infracolic compartment to the right side
of the middle colic artery into the right upper quadrant and then made
hepaticojejunostomy. We placed the Roux limb next to the common hepatic duct and
then we made a small enterotomy on the antimesenteric border measuring about 1 cm.
First, we made the posterior layer by using interrupted 4-0 PDS sutures, duct,
mucosa, and with the knots inside and then we put the anteriorly, similarly
interrupted suture of 4-0 PDS with the knots outside. After finishing the entire
anastomosis, we closed the defect in the mesocolon through which we brought the
Roux limb around the Roux limb itself using 3-0 silk interrupted sutures so that
there is no herniation and then it was noted that there was no tension on the
anastomosis. Anastomosis was pretty much watertight and then we again reexplored
the abdominal cavity just to make sure we ran the bowel again which seemed to be
well oriented without any signs of obstruction. The large bowel was also within
normal limits. Stomach was normal and then hepaticojejunostomy site was also
intact. We placed a drain through the right upper quadrant, a 19-French drain and
was placed behind the hepaticojejunostomy and secured to the skin using nylon
suture. The abdominal cavity was thoroughly irrigated, suction dried. During the
dissection of the common bile duct, lifting off the portal vein, we had at 1
point, a small tributary of the portal vein blood maybe 20 to 30 cc which was
controlled with a figure-of-eight 5-0 Prolene suture. At the end, the abdominal
wall was closed . At that time, I have left the
procedure. I performed this procedure as a co-surgeon and at
the end of the procedure, all the counts were correct. The total blood loss was
around 200 to 300 cc and the patient tolerated the procedure very well and was not
extubated and was transferred in the ICU while intubated with the plan that
patient will be extubated in the morning.