DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Morbid obesity.
POSTOPERATIVE DIAGNOSIS: Morbid obesity.
OPERATION PERFORMED:
1. Laparoscopic Roux-en-Y gastric bypass.
2. Intraoperative upper endoscopy.
SURGEON: John Doe, MD
ANESTHESIA: General with endotracheal intubation.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female who has a BMI of 40 and with comorbid features of obesity including obstructive sleep apnea, hypertension, polycystic ovarian syndrome, dyslipidemia, as well as significant dyspnea on exertion. Thus, the patient underwent education and training with the comprehensive weight management program and has elected to undergo surgical weight loss intervention.
DESCRIPTION OF OPERATION: The patient was brought back to the operating room and placed on the table in the supine position. Bilateral lower extremity venodynes were placed. The patient received a dose of IV antibiotics as well as a dose of preoperative venous thromboembolism prophylaxis with heparin. The patient was then subsequently induced via general anesthesia and intubated. The patient’s abdomen was then cleaned, prepped and draped in a surgical fashion. Opening incision was made 3-4 cm from the umbilicus approximately at the 2 o’clock position. This incision was carried down with light Bovie electrocautery dissection down to the level of the subdermis. Through this incision, we initially placed a Veress needle, and upon verifying placement of the needle with a saline drop and air bubble test, we then began CO2 insufflation to achieve pneumoperitoneal pressure of approximately 15 mmHg.
We then utilized the Optiview trocar to insert a 0 degree laparoscope through the layers of the anterior abdominal wall. Upon gaining entry into the peritoneum, we then visualized the intra-abdominal organs. There appeared to be no obvious signs of hemorrhage, no obvious signs of injury. There was also no significant pathology noted within the abdomen. Thus, at this time, we then placed all of our working trocars. Two small 5 mm trocars were placed in the bilateral subcostal margins. We then also placed two additional 12 mm working trocars bilaterally at the mid points between the 5 mm trocar and the umbilicus. We then utilized blunt dissection to identify the greater omentum and divided it at the midline. We continued our dissection towards the transverse mesocolon until we were able to gain appropriate visualization of the proximal small bowel. We then utilized blunt dissection to identify the ligament of Treitz. The small bowel was run distally to a length of approximately 40 cm, and at this point, we then divided the jejenum utilizing an Endostapler. At this time, we further dissected the mesentery of the jejenum an additional 1-2 cm. We continued our progression along the small bowel distally, this time to a length of approximately 150 cm. This was the area of the proposed jejuno-jejunal anastomosis. Thus, we reapproximated the cut end of the proximal jejenum to the distal jejenum in a side-to-side fashion and placed a stay suture utilizing a 4-0 Polysorb suture.
Following this, small enterotomies were made along the proximal distal limbs utilizing sharp and blunt dissection. We then created a side-to-side staple anastomosis utilizing an additional stapler load firing. We observed the staple line and noted it to be completely hemostatic. We then closed the enterotomy created by the stapler firing with 3 approximating sutures of additional 4-0 Polysorb to reapproximate the edges and then completely closed off the opening utilizing an additional stapler load. At this time, we paid our attention to the stomach. We placed a Nathanson retractor through an additional small 5 mm port site incision at the level of the subxiphoid space. Retracting the left lobe of the liver superiorly, we were able to visualize the gastroesophageal junction. Blunt dissection as well as some minimal sharp dissection was carried out to free up the proximal edges of the GE junction. The pars flaccida was exposed and its filmy attachments taken down sharply.
Following this, we then created a pouch utilizing series of Endostapler load firings. Thus, we were able to create a small 2-3 cm diameter size pouch of the proximal stomach. We carried out some additional sharp dissection of the fatty attachments and adhesions on the posterior aspect of the newly created pouch and then we identified the proximal aspect of the Roux limb and approximated it to the anterior surface of the pouch. We then anchored the pouch to the Roux limb utilizing an additional 4-0 Polysorb suture and a running 4-0 Polysorb suture was then utilized to create a posterior anastomosis line in an antecolic antegastric fashion.
Following this, enterotomies were made upon the pouch as well as the Roux limb and an additional stapler load was utilized to create a 1 cm anastomosis. The enterotomy was then closed utilizing interrupted 4-0 Polysorb suture. Following this, we clamped the proximal aspect of Roux limb and then performed an upper endoscopy to visualize the newly created Roux-en-Y gastric bypass anastomosis. Significant insufflation was utilized to inflate the gastric pouch as well as the proximal aspect of the Roux limb. However, there appeared to be no obvious leakage of air or intraluminal contents into the peritoneal space. Thus, we then evacuated all of the insufflation, carried out some normal saline irrigation within the peritoneum and then began removal of our retractor and working trocars.
There appeared to be complete hemostasis at the conclusion of this procedure. All of the skin incisions were then closed utilizing 4-0 Monocryl suture in a subcuticular technique. Incisions were all dressed with benzoin, Steri-Strips and Band-Aid dressings, and the patient was brought out of anesthesia and taken to the postanesthesia care unit for ongoing recovery following surgery. All sponge and needle counts were correct at the conclusion of the case. There is only very minimal bleeding.
