sandy06
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PREOPERATIVE DIAGNOSIS:
Adenocarcinoma of the gastroesophageal junction.
POSTOPERATIVE DIAGNOSIS:
Adenocarcinoma of the gastroesophageal junction.
PROCEDURE:
1. Upper GI endoscopy with repeat biopsy and injection with India ink.
2. Thoracoabdominal, minimally invasive distal esophagectomy and
proximal gastrectomy.
3. Mediastinal lymph node dissection.
4. Retroperitoneal lymph node dissection.
5. Laparoscopic feeding jejunostomy.
6. Laparoscopic lysis of adhesions.
7. Chemical pyloroplasty.
SURGEON:
MD (surgical oncology).
Co-surgeon:
MD (thoracic surgery).
First assistant:
, MD.
ANESTHESIA:
General endotracheal.
Attending anesthesiologist:
, MD.
ESTIMATED BLOOD LOSS:
50 mL.
COMPLICATIONS:
None.
Blood product replacement:
None.
DRAINS:
1. One 10-mm Blake drain draining the subhepatic space.
2. A #32 chest tube.
3. Another 10-mm Blake drain draining the mediastinum.
SPECIMENS REMOVED:
1. Distal third of the esophagus with proximal third of the stomach
with attached perigastric and retroperitoneal lymph nodes, separate
lymph nodes from station 9.
2. Anastomotic donuts from esophagogastric anastomosis.
JUSTIFICATION FOR THE PROCEDURE:
Mrs. C is an 80-year-old female that was diagnosed with
poorly-differentiated adenocarcinoma with signet cell features, after
she underwent an upper endoscopy to investigate gastrointestinal
symptoms. The biopsy was obtained from the cardia of the stomach. The
initial staging failed to reveal any evidence of metastatic or
disseminated disease. The clinical staging is a T1a, N0 M0. With these
findings, the patient comes to the operating room.
OPERATIVE FINDINGS:
The upper GI endoscopy, we did not find any gross evidence of tumor.
There was a small area of ulceration in the distal third of the
esophagus that was biopsied and what appeared to be intestinal
metaplasia at the gastroesophageal junction. There was a small area of
ulceration that was suspicious for the primary site. This area of
laceration was at the gastroesophageal junction. The distal stomach
and pylorus were within normal limits.
Intraperitoneal, we did not find any evidence of disseminated disease
and the lymph nodes were grossly negative. In the mediastinum, we also
saw only what appeared to be reactive lymph nodes and a stain from the
injection of India ink in the distal esophagus. The specimen was sent
to pathology for permanent section examination.
INFORMED CONSENT:
In the holding area, the patient signed an informed written consent. I
had explained to the patient the risk and benefits of the procedure on
her initial office visit, as well as in the visit to Dr. Ws'
office. The risks that we explained to the patient, included
anastomotic leak, bleeding, infection, and complications related to
general endotracheal anesthesia, such as deep vein thrombosis,
pulmonary emboli, and cardiac complications.
PATIENT IDENTIFICATION:
In the operating room, before the procedure was started, we took a
"time-out". Once the nurse anesthetist and the circulating nurse
agreed with the proper identification of the patient and the intended
surgical procedure, the operation was started as described below.
DESCRIPTION OF PROCEDURE:
The patient was placed supine on the operating table, and after
satisfactory general endotracheal anesthesia, a Foley catheter was
inserted, pneumatic compression boots were placed. Foley catheter was
inserted, and a central venous pressure line was placed by Dr.
Ws via the left subclavian vein. The patient then was intubated
and a bronchial divider tube was placed to be able to block the right
bronchus.
The patient then was prepared sterilely and draped sterilely. A 5-mm
incision was made above the umbilicus, through which a Veress needle
was introduced, and a pneumoperitoneum was achieved. A 5-mm Visiport
was introduced to introduce a 5-mm telescope. Once the 5-mm trocar was
introduced, we used a second 5-mm trocar in the left upper quadrant to
inspect the peritoneal cavity. The patient had previous abdominal
surgery from a hysterectomy with multiple adhesions extending to the
level of the umbilicus. We then inserted a third 5-mm trocar in the
right side of the mesogastrium, and through this trocar we introduced
Sono scissors to start taking down the adhesions. We used the
ultrasonic scalpel and laparoscopic shears alternatively to take down
the adhesions of the small bowel and great omentum from the anterior
abdominal wall. The next 45-minutes were devoted to taking down the
adhesions. Then we introduced a fourth 5-mm trocar, this one is in the
right upper quadrant, in order to separate the greater omentum from
the transverse colon. Another 45-minutes were spent mobilizing the
greater omentum away from the transverse colon, and then from the
anterior abdominal wall on the left side. Once we had this adequate
mobilization, we started dividing the greater omentum, starting from
the last branch of the gastroepiploic artery. The dissection was
continued cephalad using the ultrasonic vessel sealer and scissors.
The short gastric vessels were cauterized and transected with this
instrument. The dissection then was continued along the greater
curvature to the fundus of the stomach up to the level of the
esophageal hiatus. The patient has a hiatal hernia, and some of the
stomach was within the chest that was dissected using the Sono
scissors. We then proceeded to separate the posterior gastric wall
from the anterior wall of the stomach, and dissected the lymph nodes
around the left gastric artery. Once the left gastric artery was
isolated, it was transected with an Endo-GIA 45-mm with the tan
cartridge. The next part of the dissection was transecting the
gastrohepatic ligament all the way to the liver, starting above the
left hepatic artery and all the way to the esophageal hiatus. The
right and left crus of the diaphragm were dissected and then we
proceeded to dissect the distal third of the esophagus and the
mediastinum using the Sono scissors. Once this was accomplished, I
proceeded to dissect the lymph nodes from the lesser curvature of the
stomach, all the way to the level of the gastroesophageal junction.
The dissected lymph nodes were left attached to the specimen. After
this was accomplished, we injected 400-units of Botox in the pylorus
with a spinal needle through the anterior abdominal wall. Once this
was completed, we proceeded to retract the transverse colon cephalad
and identify the ligament of Treitz. Then 20-cm distal to the ligament
of Treitz, the loop of small bowel was grasped with a tissue grasper
and brought out to the area of the 12-mm trocar, which we had switched
from a 5 to a 12, prior to placing the stapler that transected and
stapled the left gastric artery. Once the jejunum was in the surface
of the skin, we proceeded to place a pursestring suture with 3-0
Vicryl and used an MIC feeding jejunostomy tube. The pursestring
suture was tied around the tube once the tube was inside the lumen of
the bowel, and then we proceeded to place four stitches in the serosa
at the 12, 3, and 9 radius to suture the bowel and tack it to the
fascia. Once the sutures were in place, the bowel was then
laparoscopically pulled back into the stomach and tied the tacking
sutures. After the sutures were tied down, we proceeded to place a 10-
mm drain. The drain was introduced through the 5-mm trocar site in the
left lower quadrant, and then brought out with a tissue grasper
through the trocar in the right upper quadrant. The drain then was
placed laparoscopically in the subhepatic space. At this point,
removal of the trocars and let the pneumoperitoneum out. The feeding
jejunostomy tube was stitched to the skin with nylon and then held in
place with a tube holder. The drain was sutured to the skin with 2-0
nylon. Then the trocar insertion sites were sutured with subcuticular
3-0 Vicryl for the skin and covered with Octylseal. After the
laparoscopic part was completed, we proceeded to repeat the upper
endoscopy with the findings described above, and to verify the site of
the suspected cancer. The patient then was placed in the lateral
decubitus position with the right side up, and Dr. Ws then
proceeded to perform the thoracotomy, with minimally invasive
techniques. An Alexis retractor was placed and the incision and then a
rib spreader was placed. The mediastinal dissection was carried out
with a combination of the electrocautery and the Sono scissors. After
the mediastinal dissection was carried out, the stomach was brought
onto the chest and transected using the Endo-GIA. Leaving the fundus
of the stomach with a viable blood supply. The distal esophagus was
transected at the junction with the middle third of the esophagus, and
once the specimen was out it was sent to pathology for frozen section.
We then proceeded to place an anvil after a pursestring suture was
placed in the distal esophagus using 2-0 Prolene. The anvil then was
secured where the pursestring suture was tied down. The anterior
gastric wall was opened and then the circular stapler end-to-end 25-mm
was introduced through the chest site. The circular stapler was
introduced in the stomach. The spike was brought out through the
posterior gastric wall, attached to the esophageal anvil, closed and
fired obtaining two intact tissue donuts. Under direct vision, the NG
tube was advanced by the anesthesiologist and placed in the stomach.
The gastrostomy then was closed in a transverse fashion with a
Roticulator 55 stapler. The esophagogastric anastomosis then was
reinforced with figure of eight 2-0 Prolene. Once this was completed,
a mediastinal Blake drain was left in place, a #32 chest tube was left
in place and the closure was done in the standard fashion. The skin
was approximated with subcuticular 3-0 Vicryl and then covered with
Octylseal.
At the end the procedure, the patient was extubated and transferred
back to the recovery room and eventually to the intensive care unit
with normal and stable vital signs.
Can someone please help me in coding this report, I'm very confuse on this
.
I'll appreciate any help or suggestion you can give me.
Adenocarcinoma of the gastroesophageal junction.
POSTOPERATIVE DIAGNOSIS:
Adenocarcinoma of the gastroesophageal junction.
PROCEDURE:
1. Upper GI endoscopy with repeat biopsy and injection with India ink.
2. Thoracoabdominal, minimally invasive distal esophagectomy and
proximal gastrectomy.
3. Mediastinal lymph node dissection.
4. Retroperitoneal lymph node dissection.
5. Laparoscopic feeding jejunostomy.
6. Laparoscopic lysis of adhesions.
7. Chemical pyloroplasty.
SURGEON:
MD (surgical oncology).
Co-surgeon:
MD (thoracic surgery).
First assistant:
, MD.
ANESTHESIA:
General endotracheal.
Attending anesthesiologist:
, MD.
ESTIMATED BLOOD LOSS:
50 mL.
COMPLICATIONS:
None.
Blood product replacement:
None.
DRAINS:
1. One 10-mm Blake drain draining the subhepatic space.
2. A #32 chest tube.
3. Another 10-mm Blake drain draining the mediastinum.
SPECIMENS REMOVED:
1. Distal third of the esophagus with proximal third of the stomach
with attached perigastric and retroperitoneal lymph nodes, separate
lymph nodes from station 9.
2. Anastomotic donuts from esophagogastric anastomosis.
JUSTIFICATION FOR THE PROCEDURE:
Mrs. C is an 80-year-old female that was diagnosed with
poorly-differentiated adenocarcinoma with signet cell features, after
she underwent an upper endoscopy to investigate gastrointestinal
symptoms. The biopsy was obtained from the cardia of the stomach. The
initial staging failed to reveal any evidence of metastatic or
disseminated disease. The clinical staging is a T1a, N0 M0. With these
findings, the patient comes to the operating room.
OPERATIVE FINDINGS:
The upper GI endoscopy, we did not find any gross evidence of tumor.
There was a small area of ulceration in the distal third of the
esophagus that was biopsied and what appeared to be intestinal
metaplasia at the gastroesophageal junction. There was a small area of
ulceration that was suspicious for the primary site. This area of
laceration was at the gastroesophageal junction. The distal stomach
and pylorus were within normal limits.
Intraperitoneal, we did not find any evidence of disseminated disease
and the lymph nodes were grossly negative. In the mediastinum, we also
saw only what appeared to be reactive lymph nodes and a stain from the
injection of India ink in the distal esophagus. The specimen was sent
to pathology for permanent section examination.
INFORMED CONSENT:
In the holding area, the patient signed an informed written consent. I
had explained to the patient the risk and benefits of the procedure on
her initial office visit, as well as in the visit to Dr. Ws'
office. The risks that we explained to the patient, included
anastomotic leak, bleeding, infection, and complications related to
general endotracheal anesthesia, such as deep vein thrombosis,
pulmonary emboli, and cardiac complications.
PATIENT IDENTIFICATION:
In the operating room, before the procedure was started, we took a
"time-out". Once the nurse anesthetist and the circulating nurse
agreed with the proper identification of the patient and the intended
surgical procedure, the operation was started as described below.
DESCRIPTION OF PROCEDURE:
The patient was placed supine on the operating table, and after
satisfactory general endotracheal anesthesia, a Foley catheter was
inserted, pneumatic compression boots were placed. Foley catheter was
inserted, and a central venous pressure line was placed by Dr.
Ws via the left subclavian vein. The patient then was intubated
and a bronchial divider tube was placed to be able to block the right
bronchus.
The patient then was prepared sterilely and draped sterilely. A 5-mm
incision was made above the umbilicus, through which a Veress needle
was introduced, and a pneumoperitoneum was achieved. A 5-mm Visiport
was introduced to introduce a 5-mm telescope. Once the 5-mm trocar was
introduced, we used a second 5-mm trocar in the left upper quadrant to
inspect the peritoneal cavity. The patient had previous abdominal
surgery from a hysterectomy with multiple adhesions extending to the
level of the umbilicus. We then inserted a third 5-mm trocar in the
right side of the mesogastrium, and through this trocar we introduced
Sono scissors to start taking down the adhesions. We used the
ultrasonic scalpel and laparoscopic shears alternatively to take down
the adhesions of the small bowel and great omentum from the anterior
abdominal wall. The next 45-minutes were devoted to taking down the
adhesions. Then we introduced a fourth 5-mm trocar, this one is in the
right upper quadrant, in order to separate the greater omentum from
the transverse colon. Another 45-minutes were spent mobilizing the
greater omentum away from the transverse colon, and then from the
anterior abdominal wall on the left side. Once we had this adequate
mobilization, we started dividing the greater omentum, starting from
the last branch of the gastroepiploic artery. The dissection was
continued cephalad using the ultrasonic vessel sealer and scissors.
The short gastric vessels were cauterized and transected with this
instrument. The dissection then was continued along the greater
curvature to the fundus of the stomach up to the level of the
esophageal hiatus. The patient has a hiatal hernia, and some of the
stomach was within the chest that was dissected using the Sono
scissors. We then proceeded to separate the posterior gastric wall
from the anterior wall of the stomach, and dissected the lymph nodes
around the left gastric artery. Once the left gastric artery was
isolated, it was transected with an Endo-GIA 45-mm with the tan
cartridge. The next part of the dissection was transecting the
gastrohepatic ligament all the way to the liver, starting above the
left hepatic artery and all the way to the esophageal hiatus. The
right and left crus of the diaphragm were dissected and then we
proceeded to dissect the distal third of the esophagus and the
mediastinum using the Sono scissors. Once this was accomplished, I
proceeded to dissect the lymph nodes from the lesser curvature of the
stomach, all the way to the level of the gastroesophageal junction.
The dissected lymph nodes were left attached to the specimen. After
this was accomplished, we injected 400-units of Botox in the pylorus
with a spinal needle through the anterior abdominal wall. Once this
was completed, we proceeded to retract the transverse colon cephalad
and identify the ligament of Treitz. Then 20-cm distal to the ligament
of Treitz, the loop of small bowel was grasped with a tissue grasper
and brought out to the area of the 12-mm trocar, which we had switched
from a 5 to a 12, prior to placing the stapler that transected and
stapled the left gastric artery. Once the jejunum was in the surface
of the skin, we proceeded to place a pursestring suture with 3-0
Vicryl and used an MIC feeding jejunostomy tube. The pursestring
suture was tied around the tube once the tube was inside the lumen of
the bowel, and then we proceeded to place four stitches in the serosa
at the 12, 3, and 9 radius to suture the bowel and tack it to the
fascia. Once the sutures were in place, the bowel was then
laparoscopically pulled back into the stomach and tied the tacking
sutures. After the sutures were tied down, we proceeded to place a 10-
mm drain. The drain was introduced through the 5-mm trocar site in the
left lower quadrant, and then brought out with a tissue grasper
through the trocar in the right upper quadrant. The drain then was
placed laparoscopically in the subhepatic space. At this point,
removal of the trocars and let the pneumoperitoneum out. The feeding
jejunostomy tube was stitched to the skin with nylon and then held in
place with a tube holder. The drain was sutured to the skin with 2-0
nylon. Then the trocar insertion sites were sutured with subcuticular
3-0 Vicryl for the skin and covered with Octylseal. After the
laparoscopic part was completed, we proceeded to repeat the upper
endoscopy with the findings described above, and to verify the site of
the suspected cancer. The patient then was placed in the lateral
decubitus position with the right side up, and Dr. Ws then
proceeded to perform the thoracotomy, with minimally invasive
techniques. An Alexis retractor was placed and the incision and then a
rib spreader was placed. The mediastinal dissection was carried out
with a combination of the electrocautery and the Sono scissors. After
the mediastinal dissection was carried out, the stomach was brought
onto the chest and transected using the Endo-GIA. Leaving the fundus
of the stomach with a viable blood supply. The distal esophagus was
transected at the junction with the middle third of the esophagus, and
once the specimen was out it was sent to pathology for frozen section.
We then proceeded to place an anvil after a pursestring suture was
placed in the distal esophagus using 2-0 Prolene. The anvil then was
secured where the pursestring suture was tied down. The anterior
gastric wall was opened and then the circular stapler end-to-end 25-mm
was introduced through the chest site. The circular stapler was
introduced in the stomach. The spike was brought out through the
posterior gastric wall, attached to the esophageal anvil, closed and
fired obtaining two intact tissue donuts. Under direct vision, the NG
tube was advanced by the anesthesiologist and placed in the stomach.
The gastrostomy then was closed in a transverse fashion with a
Roticulator 55 stapler. The esophagogastric anastomosis then was
reinforced with figure of eight 2-0 Prolene. Once this was completed,
a mediastinal Blake drain was left in place, a #32 chest tube was left
in place and the closure was done in the standard fashion. The skin
was approximated with subcuticular 3-0 Vicryl and then covered with
Octylseal.
At the end the procedure, the patient was extubated and transferred
back to the recovery room and eventually to the intensive care unit
with normal and stable vital signs.
Can someone please help me in coding this report, I'm very confuse on this
.I'll appreciate any help or suggestion you can give me.