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Laparoscopic Esophagomyotomy with Anterior Partial Fundoplication and Intraoperative Upper Gastrointestinal Endoscopy Operative Sample

PREOPERATIVE DIAGNOSIS:  Achalasia.

POSTOPERATIVE DIAGNOSIS:  Achalasia.

OPERATION PERFORMED:  Laparoscopic esophagomyotomy with anterior partial fundoplication and intraoperative upper gastrointestinal endoscopy.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

ANESTHESIOLOGIST:  Bradford Doe, MD

ESTIMATED BLOOD LOSS:  Less than 50 mL.

SPECIMENS:  None.

DRAINS:  None.

DESCRIPTION OF OPERATION:  The patient was positively identified preoperatively and was brought to the operating room. General endotracheal anesthesia was induced. Preoperative antibiotics were given and a Foley catheter was placed. The patient was then positioned in a split leg position. The abdomen was prepped and draped in the usual sterile fashion. An initial 1 cm incision was made just superior to the umbilicus and 12 cm from the xiphoid. The skin was grasped with two towel clips on either side and elevated. A Veress needle was then used to enter the abdomen. Entry into the abdomen was verified with saline drop test. The abdomen was then insufflated to 15 mmHg without problem. Additional trocars were placed in the following locations; 10 mm trocar along the left subcostal margin 10 mm from the xiphoid and two fingerbreadths below the subcostal margin, a 5 mm trocar two fingerbreadths below the right subcostal margin and 15 cm from the xiphoid and a 5 mm trocar in the right upper quadrant between the previously placed 5 mm trocar and the umbilical trocar. A liver retractor was then placed to the right lateral part and used to retract the liver cephalad and laterally. Final 5 mm trocar was then placed just inferior to the xiphoid making sure the course of the trocar cleared the liver edge.

Next, the pars flaccida was divided to the right using a Harmonic scalpel. The gastric fundus was then grasped and gently retracted caudally. The frontal esophageal fat pad was dissected in the space anterior to the esophagus. Entry to the mediastinum was obtained by lateral traction on the right crus and division of the peritoneum overlying the medial aspect of the crus. Dissection was carried circumferentially around the esophagus aggressively into the mediastinum until approximately 7 cm of the mediastinal esophagus was dissected free. The anterior and posterior vagus nerves were both identified and preserved. The anterior vagus nerve was then mobilized off the esophagus and the esophagocardiomyotomy was performed protecting the vagus throughout the myotomy. The adipose tissue at the region of the lower esophageal sphincter was dissected off the anterior stomach to expose the gastric wall. The anterior fibers of the esophagus were scored in the longitudinal fashion along its anterior aspect with hook cautery. At the lower esophageal sphincter, the score line was carried on the 3 cm of the gastric cardia towards the greater curve. The longitudinal fibers were then gently spread along the score line, exposing the esophageal circular muscle fibers. Hook cautery was used to divide the underlying circular fibers, exposing intact submucosa. Wide myotomy encompassing one third of the circumference of the esophagus was carried cephalad 7 cm above the lower esophageal sphincter. There was noted to be significant scarring of the muscle fibers at the upper end of the myotomy. The myotomy and the gastric cardia proceeded in a similar fashion ensuring division of all muscle fibers, including oblique fibers, with exposure of underlying mucosa on the table.

Upper gastrointestinal endoscopy was then performed and it was verified that the myotomy included the lower portion of the irregular appearing esophagus. Next, short gastric vessels were divided close to the stomach wall using Harmonic scalpel beginning midway on the greater curve and proceeding towards the angle of His. Care was taken to divide the gastrosplenic ligaments without injuring the spleen. After the fundus was mobilized, a Dor fundoplication was performed in the following fashion. The mobile fundus was pulled over the anterior esophagus. It was sutured to the myotomy on the left side with three 2-0 Ethibond sutures. The more superior suture included the left crus. It was then sutured to the myotomy on the right side once again, including the right crus in the more superior suture with three sutures of 2-0 Ethibond. Hemostasis was checked and noted to be adequate. Tisseel was injected underneath the anterior fundoplication. Secondary trocars were removed under direct vision. No bleeding was noted from the trocar site. The laparoscope was withdrawn and the umbilical trocar removed. All the trocar sites were closed with subcuticular interrupted stitches of 4-0 Monocryl and Steri-Strips. The patient tolerated the procedure without problem and was taken to the postanesthesia care unit in satisfactory condition. Dr. Doe was present and scrubbed throughout the entire procedure. Sponge and needle counts were correct x2.


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