PREOPERATIVE DIAGNOSIS: Recurrent ascites with history of breast cancer and endometrial tumor markers.
1. Recurrent ascites with history of breast cancer and endometrial tumor markers.
2. Probable peritoneal carcinomatosis.
2. Multiple biopsies.
John Doe, MD
Jane Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position on the operating table. General anesthesia was induced. Venodyne boots were then placed. A Foley catheter was inserted into the bladder. The abdomen was prepped with Betadine and draped in the usual manner. The patient was placed in Trendelenburg position. A 1 cm incision was made just above the umbilicus because of previous lower midline surgical scar. The fascia was grasped and a disposable Veress needle passed into the peritoneal cavity. Initially, low pressures were obtained and carbon dioxide was insufflated. However, the pressure became elevated with insufflation of small amount of CO2. It was therefore decided to do an open Hasson technique.
The fascia was incised between forceps. Opening identified adjoining cavity. Finger was introduced to make sure there had been no adherent bowel loops. The Hasson cannula was then introduced into the peritoneal cavity and kept in place with 2-0 Vicryl sutures. Carbon dioxide was insufflated to an intraperitoneal pressure of 15 mmHg. A laparoscope and camera were introduced and the interior of the abdomen examined. The liver had a pale pink granular appearance to it. There were fine nodules, whitish in appearance, seen on the falciform ligament, as well as on the peritoneal surface. There is also tapering of the omentum in the right upper quadrant. There were no significant tumor deposits or nodules seen. These fine miliary nodules also involved some of the bowel loops, as well as the peritoneal surfaces. It was decided to remove a sample for biopsy from the falciform ligament.
A 5 mm cannula was introduced in the right upper quadrant, as well as in the left lower quadrant. The nodules in the falciform ligament were grasped, and using the scissors and electrocautery, a biopsy specimen was obtained. This was sent to pathology. We also then decided to do a liver biopsy. The abdomen was desufflated to a pressure of 8 mmHg. A Tru-Cut needle was then introduced in the right upper quadrant, and under vision, two core biopsy specimens were obtained. These were also sent to pathology. Next, we decided to obtain a sample of the peritoneal nodules. One of these was grasped, and using electrocautery and scissors, it was shaved off and sent to pathology. Pathology reported that these represented metastatic carcinoma, probably lobular breast cancer.
After taking off the ascitic fluid, the cannula was withdrawn under vision. Hemostasis was achieved in the liver with electrocautery and also at the other biopsy sites. The fascia was closed at the umbilical site with running 0-Vicryl suture using a J needle. Marcaine 0.25% was infiltrated into all the port sites. The skin incisions were closed with 3-0 Vicryl subcutaneous and subcuticular sutures. Steri-Strips and Band-Aid dressings were applied. Blood loss was minimal. The patient tolerated the procedure well and was transferred to the recovery room in good condition.
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