DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Gastric cancer.
POSTOPERATIVE DIAGNOSIS: Gastric cancer.
1. Exploratory laparotomy.
2. Total gastrectomy with Roux-en-Y reconstruction.
3. Transverse colon resection with primary anastomosis.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General plus epidural anesthetic.
ANESTHESIOLOGIST: Bradford Doe, MD
DETAILS OF OPERATION: Following induction of general anesthesia and epidural placement, the patient was prepped and draped in standard sterile supine position. A #10 blade was then used to make a midline incision from the xiphoid process down past the umbilicus a centimeter or two. Bovie cautery was used to take down the subcutaneous tissues, and the linea alba was appreciated and opened along the midline to the preperitoneal fat. The peritoneum was retracted anteriorly and entered sharply, and this was opened along the extent of the incision. Thompson retractor blades were then placed to improve exposure to the upper quadrants, and a survey of the abdomen was performed. Initially, a small lesion along the surface of the caudate lobe was appreciated, and this was biopsied and taken off for frozen section evaluation, which returned with benign findings.
Attention was then turned to the greater omentum, which was taken off the transverse colon throughout the length of the gastrocolic ligament. Care was taken to not enter the mesocolon. Once a good distance of this was performed, some posterior attachments of the stomach wall were taken down with Bovie cautery until the mass along the posterior aspect of the lesser curve of the stomach was noted to be directly adhesed to the transverse mesocolon. At this point, we left this area alone and turned our attention to the greater curvature where the short gastrics were taken down primarily with a LigaSure device. Occasional right angle isolation of the short gastrics near the tip of the spleen was also performed with ligation with 2-0 silk ties. Once the greater curvature and cardia were completely freed to the gastroesophageal junction, we noted a fairly large lymph node at this area. This was isolated and taken off for frozen section evaluation. This returned negative for malignancy as well. The anterior aspect of the stomach did appear to have a 0.5 cm lesion near where the gastric tumor was; this was fairly well proximal. Initially, we felt that we could do a subtotal gastrectomy, however, with a good margin. Once the greater curvature was completely freed and the left gastric actually exposed posteriorly, we turned our attention back to the mesocolon involvement.
Continuing with the procedure, we decided that the patient did have resectable disease without evidence of metastasis, including the two biopsies that we sent off, and so we decided at this point to do an en bloc resection, taking the transverse mesocolon at this point with the hope that the blood supply to the transverse colon would not be compromised. This was done with LigaSure device with occasional right angle ligation of thicker tissues. This attachment was taken down en bloc, and there were some minor further posterior attachments along the stomach wall and pancreas, although these were not related to tumor involvement. This freed up the posterior aspect of the stomach in its entirety. Initially, the colon that was being perfused by the mesocolon divided, appeared viable; although, towards the end of the case and upon reevaluation, there did appear to be enough venous congestion that we felt it safer to be resected.
Using a LigaSure device, the remainder of the gastrocolic ligament was taken down to the pyloric junction. Occasional 3-0 silk ties were also placed for the perforating vessels at the pylorus. The lesser omentum was opened and cleared of connective tissue to the pylorus on the superior aspect as well. Using a 55 mm blue load GIA stapling device, the pylorus was divided at this time. Once the duodenum was transected, further dissection of the lesser curve was performed to the left gastric artery, which was identified. The peritoneal reflection along the epiphrenic fat pad was then taken down to free up further the GE junction somewhat. Then, the planned transection point along the lesser curve to create a subtotal gastrectomy was identified, and the left gastric taken down toward its base, and at this point isolated with a right angle and doubly ligated with 2-0 silks. There were no other attachments to the stomach except for just very proximally along the esophagogastric junction, and so our planned transection point was adequate.
Using a 90 mm TA stapling device, the stomach was divided at this point, leaving a small approximately 5 x 6 cm gastric pouch. Care was taken to keep the mass as well as the lesion along the anterior aspect of the stomach along the serosa included within the specimen. Once the TA stapling device was fired, crushing Kocher clamps were placed distally, and the stomach was sharply divided at this point. We opened the specimen and it looked like we had only about a 1 cm margin from the grossly involved mucosa of the gastric tumor. Initially, we decided that this would be adequate enough, as we were waiting for frozen section to return with our lymph node sampling near the GE junction. With this, we decided to create a Roux-en-Y gastrojejunostomy due to the small size of the gastric pouch.
The ligament of Treitz was identified, and approximately 20 to 30 cm downstream from this, an avascular plane was opened with Bovie cautery, and a GIA stapling device was used to come across the small bowel. The LigaSure device was then used to take down the mesentery down towards its base. This created enough mobility to bring up the Roux limb. This was brought up and with stay sutures of 3-0 silk. The remnant in stomach was placed adjacent to the Roux limb. Enterotomies were made in both the stomach and small bowel, and a 55 mm blue load stapling device was used to create a stapled anastomosis. Allis clamps and a couple of 3-0 silk ties were used to reapproximate the enterotomy, and using the 90 mm TA stapling device, the enterotomy was stapled off. With the frozen section returning with negative malignancy within the sampled lymph nodes, we reevaluated the situation and felt it best to do a total gastrectomy to have a further proximal margin, as we only had about a 1 cm gross margin with the subtotal colectomy specimen. This was felt to be appropriate for attempted curative resection.
The remaining portion of the epiphrenic fat pad was then cleared off, and some of the esophagus was mobilized from the mediastinum with an adequate length of esophagus returning into the abdomen. The Roux limb was opened along its mesentery at an avascular plane just distal to the gastrojejunostomy anastomosis and once again divided with a 55 mm blue load GIA stapling device. The remaining mesentery attached to the gastric pouch was taken off with the LigaSure, and then stay sutures of 3-0 silk were placed on either side of the esophagus, and an automatic pursestring applicator device was placed along the esophagus and fired. The remaining attachment of the esophagus to the pursestring device was taken off sharply, and this was sent for frozen section evaluation of the proximal margin, which returned clear. We still had an adequate length of Roux limb to create an EEA stapled anastomosis for an esophagojejunostomy. The pursestring applicator was then removed, and the stay sutures of 3-0 silk allowed for the esophagus not to retract into the chest.
Further buttressing with 3-0 silk sutures, placed so that the pursestring device would stay in place, and a 25 mm anvil was secured to the open esophagus and secured with the pursestring suture. This fit nicely. The stapled end of the Roux limb was then opened with sharp Mayo scissors and the EEA stapling device advanced through this, in a spike opening about 8 cm distal to the stapled end. This was connected to the anvil and the small bowel advanced onto the esophagus and then fired. The anastomosis had good donuts on either side and appeared to align nicely. Some further reinforcing 3-0 silks were placed circumferentially around this. An NG tube was placed by Anesthesia down into the distal esophagus and irrigation fluid was placed within the upper quadrant and insufflation with 25 to 60 mL of air was performed through the NG without bubbling being noted, confirming patency of the esophagojejunostomy anastomosis without leak. We were happy with this and attention was then turned to the reattachment of the proximal jejunum to the Roux limb.
About 60 cm distal to the Roux limb, the proximal jejunum was reinserted with the stapled anastomosis. First, stay sutures of 3-0 silk were placed to allow for approximation of the small bowel to be in a side-to-side fashion with each other. Then enterotomies were made with Bovie cautery and a GIA stapling device placed and fired, creating the stapled anastomosis. Stay sutures of 3-0 silk were then placed to reapproximate the enterotomy, which was closed with another firing of the 90 mm TA stapling device. This suture line was reapproximated with figure-of-eight 3-0 silks and no leak was identified with adding some pressure to the anastomosis line.
Attention was then turned once again to the transverse colon, which appeared to be having some venous congestion due to our resection of that portion of the mesocolon. It was decided safest to resect this area, and so the mesentery was opened along an avascular plane just proximally and distal to this venous congestion site, and a blue load 55 mm stapling device was used to come across the proximal and distal ends of this transverse colon. This was a segment of about 7 cm. A side-to-side stapled anastomosis along the colon was then created, first with stay sutures of 3-0 silk, then enterotomies being made within both ends of the colon, and the GIA stapler device was used to fire across, creating a stapled anastomosis. A further firing of the TA stapling device was used to close the enterotomy created with the colon stapled anastomosis. The mesentery was reapproximated with a running 3-0 silk.
The abdominal cavity was then thoroughly irrigated and hemostasis appreciated. Once we were done, we reevaluated all anastomoses and were happy with how they appeared. The abdominal contents were allowed to return to the abdomen, and the Thompson retractor blades were removed. Seprafilm was placed over the abdominal incision and the fascia was reapproximated with 0 PDS in a running fashion from either end. The subcutaneous tissues were thoroughly irrigated and staples were used to reapproximate the skin. The patient was awakened from general anesthesia, extubated, and taken to the postanesthesia care unit in stable condition. Estimated blood loss was 150 mL. Sponge and needle counts were correct.