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Lysis of Adhesions and Placement of G and J Tube Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Chronic nausea and inability to eat.

POSTOPERATIVE DIAGNOSIS:
Chronic nausea and inability to eat.

PROCEDURES PERFORMED:
1.  Exploratory laparotomy with lysis of dense adhesions.
2.  Placement of a gastrostomy tube.
3.  Placement of a jejunostomy tube.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  75 mL.

SPECIMENS:  None.

DRAINS:  An 18 French Foley catheter as a gastrostomy tube and 14 French MIC jejunostomy tube.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room and placed in the supine position. After successful introduction of general endotracheal anesthesia, the patient's abdomen was prepped and draped in a sterile fashion. A #10 blade was used to make a vertical midline incision through the previous scar. Dissection was taken down through the subcutaneous tissue to the level of the fascia, which was divided cautiously and the old PDS sutures removed. The peritoneum was cautiously entered to avoid an inadvertent enterotomy and then Metzenbaum scissors used to sharpy dissect the adhesions. The patient had significant adhesions of the stomach to the liver, as well as to the anterior abdominal wall. The lysis of adhesions was extensive and took approximately 1-1/2 hours to free up the bowel sufficiently to allow for identification of the proximal jejunum. Once the adhesions of transverse colon and omentum had been freed up satisfactorily, we were able to identify with certainty the ligament of Treitz. In this location, the small bowel was free flowing with no evidence of adhesions. This was traced distally a distance of 15 cm and this was chosen as the site of the jejunostomy. We opted not to do a full lysis of adhesions of the small bowel since we knew from preoperative testing that the patient had no obstructing lesions and that extensive lysis of adhesions could result in obstructive adhesions, as well as prolonged postoperative ileus. A 3-0 PDS was used to make a pursestring suture in the antimesenteric aspect of the jejunum. A small hole was then made in the bowel within the pursestring and then a 14 French MIC jejunostomy was placed into the defect so that the distal-most flange was within the small bowel. The pursestring suture was then tied down. A Witzel tunnel was then created to the level of the more proximal flange using 3-0 PDS sutures. Before bringing the jejunum up, we opted to place a gastrostomy tube. This would obviate the need for prolonged nasogastric tube decompression and also give the option on a more chronic basis for gastric decompression for the patient’s chronic nausea if needed. A place on the anterior aspect of the stomach was chosen for the gastrostomy tube. An 18 French Foley catheter was brought in through a separate stab wound in the left upper quadrant. Two concentric pursestring sutures of 3-0 PDS were used on the anterior aspect of the stomach to make a standard Stamm gastrostomy. A small defect in the stomach was then created concentric to these pursestrings and the Foley catheter placed into this defect and the balloon inflated with 15 mL of saline. The two pursestring sutures were then tied down, securing the gastrostomy tube in place. The stomach was then tacked circumferentially to the anterior abdominal wall using interrupted 3-0 PDS sutures. Attention was then returned back to the jejunal feeding tube. A small incision was made in the left mid quadrant and then the jejunostomy brought through the abdominal wall using the tunneling device, tunneling the jejunal tube in the rectus sheath before exiting the skin. The jejunostomy tube was then tacked to the anterior abdominal wall using 3-0 PDS, first to tack the proximal flange and then to tack the bowel circumferentially. The bowel was tacked a little more distally to prevent torsion of the jejunum. After completion, both tubes were inspected and irrigated and found to be satisfactorily positioned. The abdomen was then carefully inspected. The areas where adhesions had been lysed were inspected and there was no evidence of enterotomies noted. The wound was then closed using a running #1 Prolene for the fascia, followed by surgical staples for the skin. The patient tolerated the procedure well and was awakened and extubated without difficulty. The patient was transported to the postanesthesia care unit in stable condition without any complications apparent.