ksb0211
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I'm trying to code out this surgery and can't seem to wrap my head around it. Any help would be appreciated.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room. After attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. I made a midline incision, mobilized the stomach along the greater curvature, staying away from the epiploic vessels. Moved up around this side approaching the short gastrics and just went up through those using the Harmonic scalpel. Once we had mobilized the stomach pretty effectively, we could see where the tumor was and we put a stitch on it to mark it. We then figured out about a 4 cm margin on the tumor and we marked it as well and then came down, mobilized the lesser curvature and then realized that the way we were going to do this, we were going to put an anvil into the stomach and use a GIA and make a gastrostomy. We fired a TA90 across the body of the stomach and then cut it so that the distal end was stapled, that left the upper portion. Now we could look at the tumor up there. We took an anvil a CEEA Plus 31 mm anvil, put it up into the fundus of the stomach with a double strand of 0 silk attached to it and then came back up with the TA90 once again and fired it making sure we had the anvil away from the area that we were transecting, we got about a 3 cm margin, maybe a bit more, by the trunk after we removed it and we knew that that would happen. We then transected and we had to open up the sleeve of the stomach to make sure we did not cut our suture. Once we did that, we had our anvil up in the stomach and a suture protruding through the staple line, we carefully dissected and used the Bovie around that stitch and then pulled the anvil out so that now we had the anvil sticking out of the proximal remnant of the stomach. We then looked back at our body of the stomach and went through the staple line and introduced the CEEA Plus and then brought it through the posterior wall of the stomach, brought it up to the anvil. We had put a pursestring at the anvil proximally and then we brought our CEEA through the body of stomach; we were about 5 cm away from our anastomosis and then fired it making a 31 mm anastomosis between the proximal stomach and the distal stomach. Once that was done, we then removed a little bit of the ear of the stomach which we had using a TA60 and we looked at the results, the anastomosis looked quite good. We put down some methylene blue, that looked fine, there was no leak there and what we did then was just reinforce the proximal anastomosis with interrupted sutures of 3-0 silk. We then went down with the EGD scope, blew some air in, there was no air leak and then at this point, we decompressed and then reinforced the TA90 staple lines, making sure that we imbricated those for safety's sake. Fixed the stomach in places there would be no rotation, to both the body of the stomach and then up to the proximal gastric remnant and then made sure that that would not be torqued, placed down the suture line just proximal, an NG tube just proximal to the anastomosis and then discontinued the procedure. We irrigated, aspirated, made sure we had a dry field - we did. We closed with double stranded #1 PDS followed by deep sutures of 3-0 Vicryl followed by skin staples. The patient tolerated procedure well.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room. After attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. I made a midline incision, mobilized the stomach along the greater curvature, staying away from the epiploic vessels. Moved up around this side approaching the short gastrics and just went up through those using the Harmonic scalpel. Once we had mobilized the stomach pretty effectively, we could see where the tumor was and we put a stitch on it to mark it. We then figured out about a 4 cm margin on the tumor and we marked it as well and then came down, mobilized the lesser curvature and then realized that the way we were going to do this, we were going to put an anvil into the stomach and use a GIA and make a gastrostomy. We fired a TA90 across the body of the stomach and then cut it so that the distal end was stapled, that left the upper portion. Now we could look at the tumor up there. We took an anvil a CEEA Plus 31 mm anvil, put it up into the fundus of the stomach with a double strand of 0 silk attached to it and then came back up with the TA90 once again and fired it making sure we had the anvil away from the area that we were transecting, we got about a 3 cm margin, maybe a bit more, by the trunk after we removed it and we knew that that would happen. We then transected and we had to open up the sleeve of the stomach to make sure we did not cut our suture. Once we did that, we had our anvil up in the stomach and a suture protruding through the staple line, we carefully dissected and used the Bovie around that stitch and then pulled the anvil out so that now we had the anvil sticking out of the proximal remnant of the stomach. We then looked back at our body of the stomach and went through the staple line and introduced the CEEA Plus and then brought it through the posterior wall of the stomach, brought it up to the anvil. We had put a pursestring at the anvil proximally and then we brought our CEEA through the body of stomach; we were about 5 cm away from our anastomosis and then fired it making a 31 mm anastomosis between the proximal stomach and the distal stomach. Once that was done, we then removed a little bit of the ear of the stomach which we had using a TA60 and we looked at the results, the anastomosis looked quite good. We put down some methylene blue, that looked fine, there was no leak there and what we did then was just reinforce the proximal anastomosis with interrupted sutures of 3-0 silk. We then went down with the EGD scope, blew some air in, there was no air leak and then at this point, we decompressed and then reinforced the TA90 staple lines, making sure that we imbricated those for safety's sake. Fixed the stomach in places there would be no rotation, to both the body of the stomach and then up to the proximal gastric remnant and then made sure that that would not be torqued, placed down the suture line just proximal, an NG tube just proximal to the anastomosis and then discontinued the procedure. We irrigated, aspirated, made sure we had a dry field - we did. We closed with double stranded #1 PDS followed by deep sutures of 3-0 Vicryl followed by skin staples. The patient tolerated procedure well.