OPERATION PERFORMED: Laparoscopic lysis of adhesions.
DETAILS OF OPERATION: The patient was placed supine on the operating table, and after administration of general anesthesia, the abdomen was prepped with Betadine and draped sterilely. Saline drop test was performed to verify intraperitoneal position of the Veress needle and then CO2 insufflation was undertaken to achieve adequate pneumoperitoneum. A bladeless trocar was then used for direct entry. After 15 mmHg, pneumoperitoneum was achieved. This bladeless trocar was used under direct vision entering the peritoneal cavity. There was a minimal amount of adhesions in the mid abdomen except for adhesions of the omentum to the midline. This allowed the other five ports to be placed in a standard fashion.
Dissection was undertaken with Harmonic scalpel taking down the omental adhesion to the midline up to the falciform ligament and completely freeing the viscera from the falciform ligament. There was additionally significant adhesions causing the splenic flexure of the colon to be up around the spleen and diaphragm. These were mobilized allowing the splenic flexure of the colon to come down inferiorly and exposing the stomach.
The right side of the abdomen was inspected first and there was no obvious evidence of the adhesions in this area except for some minor omental adhesions to the gallbladder fossa after prior cholecystectomy. These were mobilized to look for other etiologies hidden behind these adhesions, none was identified. There was, however, noted a significant dilation of the duodenum. This was unexpected, as due to the bypass there is no food going through the duodenum, only bile and pancreas juice. This was followed to the ligament of Treitz and just immediately beyond the ligament of Treitz was a series of adhesions of the proximal biliopancreatic limb causing potentially a relative obstruction of that bile and pancreas juice flow from the biliopancreatic limb. It is postulated that the etiology of her right upper quadrant abdominal pain is transient, severe dilation of the duodenum which would necessitate a competent pylorus. Otherwise, bile and pancreas juices would back up into the excluded stomach. There was no evidence of dilatation of the excluded stomach.
Attention was turned to the bypass where the retrocolic-antegastric Roux limb was identified going up to a gastric pouch. Exposure of this area necessitated mobilization of the left lateral segment of the liver from the stomach. This was done up to a point. However, when it became apparent that the gastrojejunostomy was adherent very high on the lesser curvature of the gastric pouch, it was felt that if a revision were performed, we would end up with a micropouch scenario. The patient had requested us to consider making a lesser curve-based pouch with silastic ring. This did not appear to have been an option which would be tolerated well. It was felt that she may end up with essentially no gastric pouch and the dietary consequences of this.
Consequently, at the conclusion of the operation, the only thing that had been performed was a lysis of adhesions and identifying the potential relative obstruction of the duodenum, we felt we could identify the etiology for the abdominal pain and with the lysis of adhesions it was felt that we may have resolved. It is unclear, at the conclusion of the procedure, whether her abdominal pain would recur. Secondly, I felt that the gastric pouch revision was fraught with potential life style changes and potential complications which the patient may not have desired and because there was no structural defect of the pouch or gastrojejunostomy it was left intact.
Surgical findings were discussed with her husband at the completion of the procedure. All operative gasses and instrumentation were removed. Skin wounds closed with 4-0 Vicryl and Dermabond.
