ksb0211
Guest
Hoping someone has an answer or some other info for me....
PROCEDURE/OPERATION
Laparoscopic cholecystectomy and intraoperative cholangiogram, exploration of retrogastric area with biopsy of gastric mass.
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room after induction of adequate general anesthesia. The patient was prepped with DuraPrep and draped sterilely.
The initial incision was made in the infraumbilical region with a #15 blade and carried down through the subcutaneous tissues. The Veress needle was introduced and the abdomen was insufflated to 15 mmHg of pressure with CO2. Once this was done, the 5-mm Optiview trocar was passed without difficulty. Of note, the patient was noted to have a very high riding liver. He was placed in a steep Trendelenberg potion. A 5-mm port was placed in the right upper quadrant and a 10-12 port placed in the epigastrium. It was clear on observing this markedly distended and inflamed gallbladder that I would not be able to remove it from a 5-mm port. The Reddick-Saye needle was introduced and the gallbladder aspirated of some dark bile. The Reddick-Saye trocar was then passed and the gallbladder was able to be elevated to the point that I could access the cystic duct area. The cystic duct was cleared of the overlying tissue. The cystic artery was controlled with clips. A clip was placed at the level of the gallbladder neck. Intraoperative cholangiogram was performed by passing a 4-French ureteral stent. The intraoperative cholangiogram was noteworthy for a fusiform partial filling defect in the distal common duct, possibly related to clot. The patient was not completely obstructed from this process. The cystic duct was then doubly clipped and divided. The cystic artery had been controlled. The harmonic scalpel was utilized during this portion of the procedure. The gallbladder was then carefully teased from the gallbladder bed. Dissection was somewhat encumbered by the marked inflammation. Ultimately the gallbladder was able to be freed from the gallbladder bed. The argon beam coagulator was utilized and the liver bed was well cauterized. Good hemostasis was achieved. With this completed, an additional 5-mm port was placed in the left mid abdomen. The patient was rolled more to the right side. Then along the greater curvature, the harmonic scalpel was utilized and the omentum was opened. The stomach was then retracted medially and the mass was evident. Once I was able to support the mass adequately the Monopty needle was passed x 2 directly into the mass. It was an exophytic growth, somewhat dumbbell type tumor as I was aware of the findings from the endoscopy. Most of it was fairly smooth, but a nodularity was appreciated with involvement of the omentum. There was no evidence of gross metastatic disease. Findings were consistent with probably leiomyomata lesion/GIST tumor. The area was inspected for hemostasis. Once this was completed, the residual fluid in the right upper quadrant was aspirated. A 10-mm Jackson-Pratt drain was then placed via one of the lateral port sites. The upper midline incision had to be opened significantly to remove the gallbladder as it was hugely enlarged and also had large stones. The fascia was then reapproximated with interrupted 1 Monocryl. Clips were applied to the skin. All wounds were injected with 0.5% Marcaine and covered with dry sterile bandage. The patient tolerated the procedure.
47563
43659?
Any other thoughts?
PROCEDURE/OPERATION
Laparoscopic cholecystectomy and intraoperative cholangiogram, exploration of retrogastric area with biopsy of gastric mass.
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room after induction of adequate general anesthesia. The patient was prepped with DuraPrep and draped sterilely.
The initial incision was made in the infraumbilical region with a #15 blade and carried down through the subcutaneous tissues. The Veress needle was introduced and the abdomen was insufflated to 15 mmHg of pressure with CO2. Once this was done, the 5-mm Optiview trocar was passed without difficulty. Of note, the patient was noted to have a very high riding liver. He was placed in a steep Trendelenberg potion. A 5-mm port was placed in the right upper quadrant and a 10-12 port placed in the epigastrium. It was clear on observing this markedly distended and inflamed gallbladder that I would not be able to remove it from a 5-mm port. The Reddick-Saye needle was introduced and the gallbladder aspirated of some dark bile. The Reddick-Saye trocar was then passed and the gallbladder was able to be elevated to the point that I could access the cystic duct area. The cystic duct was cleared of the overlying tissue. The cystic artery was controlled with clips. A clip was placed at the level of the gallbladder neck. Intraoperative cholangiogram was performed by passing a 4-French ureteral stent. The intraoperative cholangiogram was noteworthy for a fusiform partial filling defect in the distal common duct, possibly related to clot. The patient was not completely obstructed from this process. The cystic duct was then doubly clipped and divided. The cystic artery had been controlled. The harmonic scalpel was utilized during this portion of the procedure. The gallbladder was then carefully teased from the gallbladder bed. Dissection was somewhat encumbered by the marked inflammation. Ultimately the gallbladder was able to be freed from the gallbladder bed. The argon beam coagulator was utilized and the liver bed was well cauterized. Good hemostasis was achieved. With this completed, an additional 5-mm port was placed in the left mid abdomen. The patient was rolled more to the right side. Then along the greater curvature, the harmonic scalpel was utilized and the omentum was opened. The stomach was then retracted medially and the mass was evident. Once I was able to support the mass adequately the Monopty needle was passed x 2 directly into the mass. It was an exophytic growth, somewhat dumbbell type tumor as I was aware of the findings from the endoscopy. Most of it was fairly smooth, but a nodularity was appreciated with involvement of the omentum. There was no evidence of gross metastatic disease. Findings were consistent with probably leiomyomata lesion/GIST tumor. The area was inspected for hemostasis. Once this was completed, the residual fluid in the right upper quadrant was aspirated. A 10-mm Jackson-Pratt drain was then placed via one of the lateral port sites. The upper midline incision had to be opened significantly to remove the gallbladder as it was hugely enlarged and also had large stones. The fascia was then reapproximated with interrupted 1 Monocryl. Clips were applied to the skin. All wounds were injected with 0.5% Marcaine and covered with dry sterile bandage. The patient tolerated the procedure.
47563
43659?
Any other thoughts?