ksb0211
Guest
This is not a surgery that our providers normally do. Because it seems that this was an involved case and I'm not familiar, I'm hoping for some direction. Any help would be greatly appreciated.
PREOPERATIVE DIAGNOSIS
Paraesophageal hernia with gastric volvulus.
POSTOPERATIVE DIAGNOSIS
Paraesophageal hernia with gastric volvulus with impending gastric ischemia.
OPERATION PERFORMED
1. Reduction of incarcerated paraesophageal hernia.
2. Repair of paraesophageal hernia.
3. Imbrication of impending gastric necrosis.
4. Placement of Moss feeding tube.
ESTIMATED BLOOD LOSS
Less than 50 mL.
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. A midline incision was made above the umbilicus and we entered the abdominal cavity, found some fluid present in the abdominal cavity. The stomach initially looked normal but as we put some gentle traction on it we pulled out a large portion of the fundus of the stomach. There was a band that went around the stomach that showed it was ischemic and we then put further traction on it and then found some necrotic fat and omental material which we resected from the hernia sac. This left us with the crux of the diaphragm which is pretty well defined. We looked at the stomach and made the decision whether or not this was going to be viable. It really did look. Viable there was just this 1 band that area that did not look as good as it could have and we elected just to imbricate that using interrupted sutures of 3-0 Vicryl, covering the entire area. Once that was done, we placed a 52 French bougie down the esophagus and then carried our repair of the defect. We reduced the sac and carried out the repair with interrupted sutures of figure-of-8 of 0 silk. That was reduced the defect significantly. The defect originally was probably about 3 to 4 cm in diameter. We reduced it back to about 1 cm. We did not want to make it too tight. At this point, we had the stomach down and repaired. We put a Moss feeding gastrostomy tube in. We kocherized the duodenum, introduced the tube, got it into position out the duodenum, inflated the balloon. We had 2 pursestring sutures of 2-0 silk, secured that up against the abdominal wall, put a little bit of traction on the balloon as well and then tacked the stomach in 2 separate areas, 1 at the level of the antrum another 1 up over toward the body to tack the stomach to the anterior abdominal wall. We then irrigated, aspirated and then turned our attention to closure. We closed with running suture #1 PDS followed by irrigation followed by staples. The patient tolerated procedure well.
PREOPERATIVE DIAGNOSIS
Paraesophageal hernia with gastric volvulus.
POSTOPERATIVE DIAGNOSIS
Paraesophageal hernia with gastric volvulus with impending gastric ischemia.
OPERATION PERFORMED
1. Reduction of incarcerated paraesophageal hernia.
2. Repair of paraesophageal hernia.
3. Imbrication of impending gastric necrosis.
4. Placement of Moss feeding tube.
ESTIMATED BLOOD LOSS
Less than 50 mL.
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. A midline incision was made above the umbilicus and we entered the abdominal cavity, found some fluid present in the abdominal cavity. The stomach initially looked normal but as we put some gentle traction on it we pulled out a large portion of the fundus of the stomach. There was a band that went around the stomach that showed it was ischemic and we then put further traction on it and then found some necrotic fat and omental material which we resected from the hernia sac. This left us with the crux of the diaphragm which is pretty well defined. We looked at the stomach and made the decision whether or not this was going to be viable. It really did look. Viable there was just this 1 band that area that did not look as good as it could have and we elected just to imbricate that using interrupted sutures of 3-0 Vicryl, covering the entire area. Once that was done, we placed a 52 French bougie down the esophagus and then carried our repair of the defect. We reduced the sac and carried out the repair with interrupted sutures of figure-of-8 of 0 silk. That was reduced the defect significantly. The defect originally was probably about 3 to 4 cm in diameter. We reduced it back to about 1 cm. We did not want to make it too tight. At this point, we had the stomach down and repaired. We put a Moss feeding gastrostomy tube in. We kocherized the duodenum, introduced the tube, got it into position out the duodenum, inflated the balloon. We had 2 pursestring sutures of 2-0 silk, secured that up against the abdominal wall, put a little bit of traction on the balloon as well and then tacked the stomach in 2 separate areas, 1 at the level of the antrum another 1 up over toward the body to tack the stomach to the anterior abdominal wall. We then irrigated, aspirated and then turned our attention to closure. We closed with running suture #1 PDS followed by irrigation followed by staples. The patient tolerated procedure well.