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Laparotomy Small Bowel Resection Jejunostomy Sample


PREOPERATIVE DIAGNOSIS:  Small bowel anastomotic leak.

POSTOPERATIVE DIAGNOSIS:  Small bowel anastomotic leak.

OPERATIONS PERFORMED:  Exploratory laparotomy; small bowel resection, approximately 1.5 feet; jejunostomy; mucous fistula; placement of an abdominal wound VAC.

SURGEON:  John Doe, MD 

ANESTHESIA:  General endotracheal anesthesia.

SPECIMENS:  Small bowel, approximately 1.5 feet.



DESCRIPTION OF OPERATION:  The patient was brought to the operating suite and placed in the supine position. General anesthesia was induced. The previously placed wound VAC and Wittmann Patch were then removed without complications. The omentum was adhesed to the anterior small bowel and this was taken down with blunt finger dissection. The small bowel anastomosis was located in the right lower quadrant of her abdominal wound, and upon examination, there was evidence of a 0.5 cm defect at the staple line, which was leaking succus into the abdominal cavity. The loops of small bowel were then traced back. The proximal portion of the anastomosis was traced back to the ligament of Treitz. The estimated distance was approximately 65 cm. The distal portion of the anastomosis was only able to be mobilized approximately 20 cm. Upon distal mobilization of the small bowel, we were able to examine the uterus, which appeared normal, as well as what appeared to be the right fallopian tube. The sigmoid colon and descending colon appeared to be normal without any gross defects. It was decided that the safest procedure to perform was to bring out a proximal jejunostomy and a distal jejunostomy/mucous fistula. The proximal portion of the small bowel was transected using a blue load 55 mm handheld GIA stapler after creating a small opening in the mesentery. The mesentery was mobilized using a handheld LigaSure device, and after making an approximately 4 cm circular opening in her anterior abdominal wall and in her left lower quadrant, the loop of proximal jejunum was brought out through this opening. The small bowel was suture tacked to the anterior abdominal wall with a 3-0 Vicryl suture. The distal jejunum was then also transected using a single 55 mm blue load GIA handheld stapler and the mesentery of this portion of small bowel was also mobilized using a handheld LigaSure device. A second 4 cm circular opening was made in her anterior abdominal wall, in the right lower quadrant, and the distal jejunum was brought out through this opening as well. The small bowel was once again tacked to the anterior abdominal wall using a single 3-0 Vicryl suture. The anastomosis was then completely transected and sent to pathology for further evaluation. The total length of small bowel removed was approximately 1.5 feet. The abdominal cavity was then irrigated using warm normal saline. Hemostasis was achieved using a combination of electrocautery as well as suture ligatures. The proximal jejunostomy and distal jejunostomy were then matured in a normal fashion using interrupted 3-0 Vicryl sutures. The abdominal wound was then covered with an abdominal wound VAC and this was placed to suction. Ostomy bags were then placed over the 2 newly created stomas in the normal fashion. The patient was then brought out of general anesthesia and transferred back to the surgical intensive care unit in critical condition. Estimated blood loss for the procedure was 250 mL. There were no complications. The specimen removed was a total of approximately 1.5 feet of small bowel, which was sent to pathology for further evaluation. Needle and sponge counts were correct x2.