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Graham Patch Repair and G and J Tube Placement Sample


PREOPERATIVE DIAGNOSIS:  Acute abdomen and sepsis.

POSTOPERATIVE DIAGNOSIS:  Perforated duodenal ulcer and peritonitis.

OPERATIONS PERFORMED:  Exploratory laparotomy, Graham patch repair of perforated duodenal ulcer, gastrojejunostomy and feeding jejunostomy placement, Witzel type.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal intubation.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old male who was admitted to the intensive care unit with complaints of abdominal pain as well as physical examination and clinical findings consistent with cardiovascular shock, presumably secondary to sepsis. The patient was monitored in the intensive care unit and over the course of the previous 24 hours has had increasing requirements for critical care support including intubation with mechanical ventilation as well as increased abdominal distention. A diagnostic peritoneal lavage was performed at the bedside, which was positive for gastric contents. Rationale, risks and benefits of surgery were discussed with the patient's brother and an informed consent was obtained. Given the critical nature of the patient's illness, emergent exploratory laparotomy was scheduled and the patient was taken down for surgery.

DESCRIPTION OF OPERATION:  The patient was brought down from the intensive care unit and placed on the operating room table. The patient was sedated with fentanyl as well as Versed IV drip, induced with anesthesia, and mechanical ventilation was continued through a previously placed endotracheal tube. Bilateral lower extremity Venodyne was placed. The patient received approximately 6 units of fresh frozen plasma, given coagulopathic state with INR of 1.9 prior to surgery. In addition, the patient received a dose of DDAVP given his acute renal failure and possible uremic source of bleeding. At this time, the patient's abdomen was cleaned, prepped and draped in a surgical fashion. An opening incision was made in the midline running from the subxiphoid process, beyond the umbilicus. We incorporated the previous DPL incision site and took down the nylon sutures, which were previously placed. The incision was carried down with electrocautery dissection down to the level of the peritoneum, which was entered under direct visualization utilizing a scalpel and further continued with electrocautery dissection. Upon entering into the abdomen, there were gastric contents. The ascitic fluid was significant for turbidity as well as what appeared to be food particles. This fluid was all suctioned out and we began exploration of the abdomen.  We began in the right upper quadrant and immediately were able to visualize a large perforated duodenal viscus. The duodenal perforation appeared to be approximately 1 cm in size. The wall of the surrounding tissues appeared to be significantly inflamed with firm thickening and woody inflammation of the surrounding tissues. Mucosa was also very inflamed; however, it appeared to be intact. It was not friable and it was separated well, given the inflammatory changes, away from the muscular layer. The gallbladder appeared to be within normal limits.  Although there was some minor erythema within the wall of the gallbladder, it appeared to be viable. It did not appear to be acutely affected by biliary disease. Thus, the gallbladder was left intact. We were concerned that the perforation of the duodenum was in an area in close approximation to the common bile duct and thus, given this, we attempted to repair the defect carefully without affecting the biliary tree. We began with dissection of the gastrocolic ligament, taking down the mesenteric attachments between the two organs and we were able to, with some minor manipulation, get into a plane allowing us access to the posterior wall of the stomach. We continued our blunt dissection and manipulation of the stomach to encircle the stomach in its entirety and we then placed a Penrose drain from the lesser curvature and encircling the entire distal stomach. We identified the pylorus again and we fired a TA stapler across the distal portion of the stomach to exclude the stomach from the perforated duodenum. Following this, we then closed the mucosal defect at the perforation utilizing interrupted 3-0 Vicryl sutures x3. Following mucosal closure, we then placed a patch of viable omentum over the entire defect and we placed four interrupted 2-0 silk sutures to approximate the entire duodenal defect and we then tied these sutures down over the patch of omentum, effectively closing off the entire defect in a Graham patch fashion. Following this, we irrigated the entire abdomen with diluted Betadine with normal saline solution. We utilized copious amounts of this solution to irrigate out the entire abdomen until the effluent was noted to be completely clear. Following thorough irrigation, we continued thorough exploration of the abdomen. The stomach as well as the left upper quadrant appeared to be without any signs of pathology. The left lower quadrant appeared to be also without any obvious signs of pathology. The small bowel was run from the ligament of Treitz down towards the terminal ileum, and as we approached within 2 feet of the terminal ileum, we identified Meckel diverticulum; however, the diverticulum appeared to be completely healthy in appearance; it did not appear to be inflamed. There was no pathology, and given the patient's critical status, we elected to forego any surgical intervention at this time. We continued the exploration down towards the right lower quadrant and identified the appendix, and at this point, we identified a collection of some fluid which appeared to be turbid, which was tracking from the deep pelvis.  Thus, we irrigated the entire pelvis again with some further amounts of diluted Betadine with normal saline solution, and after several cycles of irrigation, we noted the effluent was clear. There did not appear to be any perforations or other sources of the fluid and it was presumably a collection that had tracked down to the most dependent portion of the abdomen. After thoroughly exploring the abdomen and irrigating out the abdominal contents, we then paid attention back to the stomach. We brought up a loop of jejunum approximately 40 to 50 cm from the ligament of Treitz proximally towards the stomach in an antecolic fashion and we then placed 2 stay sutures of 3-0 silk suture to approximate the stomach to the jejunum, in preparation for gastric jejunostomy. At this point, we laid down a series of 3-0 silk sutures in an interrupted fashion to serve as a back row of the gastrojejunostomy and we then opened a gastrotomy as well as jejunotomy openings utilizing electrocautery dissection. Following this, we then sutured the mucosa of the jejunum to the mucosa of the stomach utilizing 2 running 3-0 Vicryl sutures, and upon completion of the gastric jejunostomy, we then placed another series of 3-0 silk sutures to serve as the anterior wall of the gastrojejunostomy. Following completion of the gastrojejunostomy, we palpated the opening and noted it to be widely patent without any obvious signs of puckering or stricture. At this time, we identified an appropriate place distal from the gastric jejunostomy upon the jejunal approximately an additional 40 to 50 cm distal to the gastrojejunostomy. We then placed a pursestring 3-0 silk suture, and at the mid point of the pursestring, we opened another jejunotomy utilizing electrocautery dissection. Through this, we placed a 12 French feeding tube and tied the pursestring suture to fasten the feeding tube in place. We placed some additional interrupted 3-0 silk sutures in a Witzel technique to further fasten the feeding tube in place and to minimize the chance of leak. We carried out the Witzel sutures approximately 3 to 4 cm in length from the point of opening. Following this, we then delivered the distal end of the feeding tube through the anterior abdominal wall on the left side of the abdomen, utilizing a small skin incision and the tonsil clamps. We then sutured the portion of small bowel to the anterior abdominal wall utilizing the interrupted 3-0 silk sutures that had been placed prior, in order to bury the feeding tube within the jejunum. Following this, we sutured the distal end of the feeding tube at the level of the skin utilizing a 3-0 nylon suture. At this time, we placed a large Jackson-Pratt drain at the dissection bed and delivered the distal end through the skin on the right side of the abdomen utilizing the scalpel and tonsil clamp. We then sutured this drain at the level of the skin utilizing a 2-0 nylon suture. At this time, we then carried out some additional irrigation of the skin and subdermal tissues and we then began closure of the abdomen. We closed the fascia utilizing 2 running 0 loop Maxon sutures. At the conclusion of the fascia closure, we irrigated out the subdermal tissues and skin utilizing additional dilute Betadine and normal saline solution. We then placed one 2-0 nylon suture at the level of the skin just at the mid point of the incision to approximate the incision in a vertical mattress suture technique. The skin was then left open and the wound was packed with normal saline-soaked gauze and dressed with ABD pads. The drain and feeding tube were also dressed with drain sponges, and the patient was then brought out of anesthesia and taken back to the intensive care unit for ongoing recovery following the surgery. The patient tolerated the procedure well. There were no significant complications. All sponge and needle counts were correct at the conclusion of the case. The patient had approximately 200 mL of estimated blood loss.  The patient received 8 units of FFP total at the conclusion of the case.

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