Codehound1
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PREOP and POSTOPERATIVE DIAGNOSES: Perforated duodenal ulcer, elevated total bilirubin with liver enzymes.
PROCEDURES PERFORMED:
Exploratory laparotomy with washout.
Primary repair of duodenal ulcer.
Creation and placement of falciform ligament flap.
Cholecystectomy with cholangiogram.
SPECIMENS: Gallbladder.
FINDINGS: A 3.5 cm perforation of the anterior duodenum. Matching inflamed/necrotic area of the gallbladder was identified immediately adjacent to this area. The duodenum was quite patulous and the edges of the ulcer was clean and viable with minimal induration and good pliability. The gallbladder was edematous and inflamed. Intraoperative cholangiogram revealed no filling defects, and a patent common bile duct. The liver appeared grossly normal.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and underwent induction of general anesthesia. She was placed in the supine position with all pressure points well padded and her abdomen was prepped and draped in standard sterile surgical fashion. An upper midline incision was created and the abdomen was carefully entered and upon entering the abdomen, I carefully took down and mobilized a falciform ligament flap. A large Alexis wound retractor was utilized as was the Bookwalter retractor. The abdomen was explored with the findings as described above. Because of the patient's elevated total bilirubin and transaminases and with a stone versus other object within the gallbladder, I elected to perform a cholecystectomy with cholangiogram. The gallbladder was grasped with a large clamp and dissected in a top-down approach, identifying the cystic duct and cystic artery without difficulty. The artery was ligated and an intraoperative cholangiogram was performed revealing findings as described above. The duct was then ligated with a single Vicryl ligature and a large metal clip. Attention was then turned towards the duodenum. Again the rent in the duodenum was actually quite large. The duodenum was patulous and freely mobile and I felt that it would be easily closed in a transverse direction. This was then accomplished using multiple interrupted 3-0 Vicryl sutures. After complete closure of the defect transversely, I replaced the NG tube across the area of repair and then performed a second layer of 3-0 Vicryl Lembert sutures. The falciform ligament flap was then stitched over the area in 4 locations. A 19 round Blake drain was placed in the right upper quadrant and the abdomen was copiously irrigated. The fascia was closed with a running #1 looped PDS suture. The subcutaneous tissues were irrigated. The skin was closed with clips.
PREOP and POSTOPERATIVE DIAGNOSES: Perforated duodenal ulcer, elevated total bilirubin with liver enzymes.
PROCEDURES PERFORMED:
Exploratory laparotomy with washout.
Primary repair of duodenal ulcer.
Creation and placement of falciform ligament flap.
Cholecystectomy with cholangiogram.
SPECIMENS: Gallbladder.
FINDINGS: A 3.5 cm perforation of the anterior duodenum. Matching inflamed/necrotic area of the gallbladder was identified immediately adjacent to this area. The duodenum was quite patulous and the edges of the ulcer was clean and viable with minimal induration and good pliability. The gallbladder was edematous and inflamed. Intraoperative cholangiogram revealed no filling defects, and a patent common bile duct. The liver appeared grossly normal.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and underwent induction of general anesthesia. She was placed in the supine position with all pressure points well padded and her abdomen was prepped and draped in standard sterile surgical fashion. An upper midline incision was created and the abdomen was carefully entered and upon entering the abdomen, I carefully took down and mobilized a falciform ligament flap. A large Alexis wound retractor was utilized as was the Bookwalter retractor. The abdomen was explored with the findings as described above. Because of the patient's elevated total bilirubin and transaminases and with a stone versus other object within the gallbladder, I elected to perform a cholecystectomy with cholangiogram. The gallbladder was grasped with a large clamp and dissected in a top-down approach, identifying the cystic duct and cystic artery without difficulty. The artery was ligated and an intraoperative cholangiogram was performed revealing findings as described above. The duct was then ligated with a single Vicryl ligature and a large metal clip. Attention was then turned towards the duodenum. Again the rent in the duodenum was actually quite large. The duodenum was patulous and freely mobile and I felt that it would be easily closed in a transverse direction. This was then accomplished using multiple interrupted 3-0 Vicryl sutures. After complete closure of the defect transversely, I replaced the NG tube across the area of repair and then performed a second layer of 3-0 Vicryl Lembert sutures. The falciform ligament flap was then stitched over the area in 4 locations. A 19 round Blake drain was placed in the right upper quadrant and the abdomen was copiously irrigated. The fascia was closed with a running #1 looped PDS suture. The subcutaneous tissues were irrigated. The skin was closed with clips.