DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Pancreatic necrosis and abscess.
2. Shock.
POSTOPERATIVE DIAGNOSIS:
Pancreatic necrosis.
PROCEDURE PERFORMED:
1. Exploratory laparotomy with pancreatic necrosectomy and debridement.
2. Jejunostomy tube placement.
3. Placement of sump drain at the pancreatic bed.
SURGEON: John Doe, MD
PROCEDURE FINDINGS:
1. Two liters of cloudy ascitic fluid.
2. No evidence of bowel ischemia.
3. No evidence of bowel perforation.
4. Necrosis of the pancreas secondary to severe pancreatitis.
ESTIMATED BLOOD LOSS: Approximately 100 mL.
CONDITION: Critical.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was taken to the OR and prepped and draped in sterile fashion. An upper midline incision was made. Upon entering the abdominal cavity, approximately 2 liters of cloudy, yellowish ascitic fluid was immediately aspirated. The liver appeared to have nodular appearance consistent with cirrhosis.
We began the procedure by inspecting the entire GI tract. The GE junction was identified. Anterior aspect of the stomach, pylorus and duodenum were all identified. There were no signs of perforations or ulcerations. Ligament of Treitz also identified. The bowel was run distally until the terminal ileum. Again, there were no signs of ischemia. No signs of perforation. The cecum was inspected. The ascending colon, transverse colon, descending colon and rectum were all inspected and there were no signs of perforations or ischemia. We began with the next step and continued with entering into lesser sac. The omentum was dissected off the inferior surface of the transverse colon to gain entrance into the lesser sac. The stomach appeared to be densely adherent to the underlying pancreatic tissue. We were finally able to get through after dissection with the Harmonic scalpel. There was a large cavity with cloudy semisolid tissue consistent with pancreatic necrosis. All these areas were then irrigated with saline solution. All the necrotic semisolid material was removed. The mesocolon was also divided at this location to gain better entrance of this cavity. The ascitic fluid and the pancreatic fluid were all submitted for cultures. The abdominal cavity was irrigated with copious amount of saline solution until clear.
Next, we continued with placing a J-tube. Two pursestring 3-0 silk sutures were placed in the anterior aspect of the distal stomach. Gastrostomy was opened. A 16-French Foley was then brought out through a separate stab incision in the left lower quadrant and placed into the stomach. The balloon was inflated to 10 mL. The stomach was then tacked up to the anterior abdominal wall with multiple circumferentially placed 3-0 silk sutures. Next, an Abramson sump drain was then brought in through a stab incision in the left mid abdominal area. The drain was then placed into the lesser sac aiming towards the head of the pancreas. Additionally, a 10 mm flat JP drain was then placed into the pancreatic cavity and placed distally and brought through a separate stab incision on the patient’s right side.
Additionally, the proximal jejunum was identified. Again, two 3-0 silk pursestring sutures were then placed in the anterior aspect. Again, a 16-French Foley catheter was then brought in through a separate stab incision, this time in the left mid abdomen and introducing to the lumen. Then, 3 mL of balloon was inflated only. This loop of small bowel was also tied up to the anterior abdominal wall. The fascia was then reapproximated with #1 Vicryl placed in an interrupted fashion. Three #2 nylon suture were used as retention suture to close in a full-thickness fashion. The skin was approximated with skin staples. The patient returned to the intensive care unit, but remained in critical condition.
