DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Gastric cancer.
POSTOPERATIVE DIAGNOSIS: Gastric cancer.
OPERATIONS PERFORMED: Gastrectomy with extended lymphadenectomy, including en bloc distal pancreatectomy, splenectomy, cholecystectomy, and placement of anti-adhesion barrier.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS: Gastric cancer.
OPERATIVE FINDINGS: The stomach appeared leathery throughout the body. The wall was thickened. No overt penetration of tumor. No overt involvement of adjacent organs. Lymph nodes in region of left gastric artery appeared suspicious clinically.
DESCRIPTION OF OPERATION: The patient was prepped and draped in the standard fashion. An upper midline laparotomy incision was made. The peritoneal cavity was entered and no carcinomatosis was encountered. The liver appeared clear. The abdomen was explored. It was notable for a fairly thick-walled stomach, particularly in the area of the body. There was no overt extension of the tumor anteriorly as I could visualize. The gallbladder appeared pale and shriveled. This was consistent with chronic cholecystitis. We elevated the omentum off of the colon and then entered the lesser sac. The adventitial tissue connecting the stomach to the pancreas was taken down using electrocautery. Again, there was no overt extension here. There were, however, palpable lymph nodes, small in size, but hard and irregular and more noticeable than other lymph node basins in the distribution of the left gastric artery and splenic artery region, in the distribution of the left gastric vein and splenic vein region. Because of this, we felt the patient should undergo an extended lymphadenectomy. Because of the diffuse nature of the tumor with leathery stomach, we felt that the patient should undergo a total gastrectomy.
The omentum was completely mobilized and left tethered to the stomach. The spleen was then elevated along with the pancreas and separated from surrounding structures. A Bookwalter retractor was used to facilitate exposure. The greater curvature attachments were taken down off of the stomach. Well beyond the pylorus, the duodenum was divided using the endovascular GIA. Lesser curvature was then taken using the LigaSure device as close to the liver as possible. No clinically palpable nodes were appreciated here. The tail of the pancreas was then divided. The spleen was elevated up, remained connected to the stomach with the short gastrics, and was separated from its posterior and other attachments. The cardia was then dissected out and the gastroesophageal junction was identified. Two 3-0 PDS sutures were placed on either side of the esophagus and the gastroesophageal junction was divided using electrocautery. Grossly, this margin as well as the duodenal margin appeared clear. Posteriorly, the remaining attachments including the neurovascular bundle of the left gastrics were divided, taking great care to identify the hepatic and splenic vessels. We took the gastric artery right at its base, incorporating all of the lymph nodes. Splenic artery lymph node, splenic hilum lymph node, peripancreatic lymph nodes, as well as hepatic artery lymph nodes were included in the specimen, not to mention all the perigastric lymph nodes. The specimen was handed off the field and confirmed that distal and proximal margins were negative. We next began the reconstruction.
First, retrograde cholecystectomy was performed, keeping a critical view of safety in mind, including both the cystic artery and cystic duct. Hemostasis was assured with electrocautery and Surgicel. The ligament of Treitz was identified, and approximately 40 cm distal to this, the bowel was divided. The mesentery was divided using the LigaSure. The distal bowel was brought up antecolic and an end-to-side esophagojejunostomy was performed using interrupted 3-0 PDS. The jejunum was secured to the paraesophageal region using 2-0 silk sutures. The NG tube was threaded through down into the proximal jejunum. Distally, a side-to-side functional, end-to-end anastomosis was performed, bringing the small bowel together. This was approximately at 40 cm from the esophagojejunostomy. This was done using the GIA and TA-60. The TA-60 actually appeared to narrow the Roux limb slightly, and for that reason, an even more proximal enteroenterostomy performed in the same fashion was made to prevent obstruction. All staple lines were oversewn. They appeared viable. A redundant portion of the duodenal end of the small bowel was resected as it looked slightly dusky. Again, by the end of the case, the patient was hemostatic, her bowel appeared viable, all potential areas of internal herniation had been closed using 2-0 suture, and all suture lines were oversewn using silk suture.
A Witzel feeding jejunostomy was placed in the duodenal limb near the ligament of Treitz. A 2-0 silk was used also outside of the Witzel technique to pexy this to the posterior abdominal wall. The tube was flushed and there was evidence of leakage. Its distal limb was threaded into the proximal enteroenterostomy. We then oversewed the duodenal stump using interrupting Vicryl 2-0 as well as the pancreatic margin. Two large Blake drains were placed from the right side near the anastomosis, duodenal stump and pancreatic staple line. All drains and feeding tubes were secured with multiple 2-0 silk suture. The viscera were then oriented and reinspected, and we irrigated with significant amounts of fluid and all effluent was removed. The patient was hemostatic. Lap, needle, and instrument counts were deemed correct x2 and then furthermore at the end of the case. Seprafilm was placed atop the viscera as it was oriented properly. The fascia was then closed using heavy PDS suture. The skin was stapled after irrigating subcutaneous tissues. Betadine ointment was placed to all drain sites and staples along with dry dressings. The patient appeared to tolerate the procedure. We explained all the aforementioned, including the extent of the surgery and the reason an extended lymphadenectomy had been performed.
PREOPERATIVE DIAGNOSIS: Gastric cancer.
POSTOPERATIVE DIAGNOSIS: Gastric cancer.
OPERATIONS PERFORMED: Gastrectomy with extended lymphadenectomy, including en bloc distal pancreatectomy, splenectomy, cholecystectomy, and placement of anti-adhesion barrier.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS: Gastric cancer.
OPERATIVE FINDINGS: The stomach appeared leathery throughout the body. The wall was thickened. No overt penetration of tumor. No overt involvement of adjacent organs. Lymph nodes in region of left gastric artery appeared suspicious clinically.
DESCRIPTION OF OPERATION: The patient was prepped and draped in the standard fashion. An upper midline laparotomy incision was made. The peritoneal cavity was entered and no carcinomatosis was encountered. The liver appeared clear. The abdomen was explored. It was notable for a fairly thick-walled stomach, particularly in the area of the body. There was no overt extension of the tumor anteriorly as I could visualize. The gallbladder appeared pale and shriveled. This was consistent with chronic cholecystitis. We elevated the omentum off of the colon and then entered the lesser sac. The adventitial tissue connecting the stomach to the pancreas was taken down using electrocautery. Again, there was no overt extension here. There were, however, palpable lymph nodes, small in size, but hard and irregular and more noticeable than other lymph node basins in the distribution of the left gastric artery and splenic artery region, in the distribution of the left gastric vein and splenic vein region. Because of this, we felt the patient should undergo an extended lymphadenectomy. Because of the diffuse nature of the tumor with leathery stomach, we felt that the patient should undergo a total gastrectomy.
The omentum was completely mobilized and left tethered to the stomach. The spleen was then elevated along with the pancreas and separated from surrounding structures. A Bookwalter retractor was used to facilitate exposure. The greater curvature attachments were taken down off of the stomach. Well beyond the pylorus, the duodenum was divided using the endovascular GIA. Lesser curvature was then taken using the LigaSure device as close to the liver as possible. No clinically palpable nodes were appreciated here. The tail of the pancreas was then divided. The spleen was elevated up, remained connected to the stomach with the short gastrics, and was separated from its posterior and other attachments. The cardia was then dissected out and the gastroesophageal junction was identified. Two 3-0 PDS sutures were placed on either side of the esophagus and the gastroesophageal junction was divided using electrocautery. Grossly, this margin as well as the duodenal margin appeared clear. Posteriorly, the remaining attachments including the neurovascular bundle of the left gastrics were divided, taking great care to identify the hepatic and splenic vessels. We took the gastric artery right at its base, incorporating all of the lymph nodes. Splenic artery lymph node, splenic hilum lymph node, peripancreatic lymph nodes, as well as hepatic artery lymph nodes were included in the specimen, not to mention all the perigastric lymph nodes. The specimen was handed off the field and confirmed that distal and proximal margins were negative. We next began the reconstruction.
First, retrograde cholecystectomy was performed, keeping a critical view of safety in mind, including both the cystic artery and cystic duct. Hemostasis was assured with electrocautery and Surgicel. The ligament of Treitz was identified, and approximately 40 cm distal to this, the bowel was divided. The mesentery was divided using the LigaSure. The distal bowel was brought up antecolic and an end-to-side esophagojejunostomy was performed using interrupted 3-0 PDS. The jejunum was secured to the paraesophageal region using 2-0 silk sutures. The NG tube was threaded through down into the proximal jejunum. Distally, a side-to-side functional, end-to-end anastomosis was performed, bringing the small bowel together. This was approximately at 40 cm from the esophagojejunostomy. This was done using the GIA and TA-60. The TA-60 actually appeared to narrow the Roux limb slightly, and for that reason, an even more proximal enteroenterostomy performed in the same fashion was made to prevent obstruction. All staple lines were oversewn. They appeared viable. A redundant portion of the duodenal end of the small bowel was resected as it looked slightly dusky. Again, by the end of the case, the patient was hemostatic, her bowel appeared viable, all potential areas of internal herniation had been closed using 2-0 suture, and all suture lines were oversewn using silk suture.
A Witzel feeding jejunostomy was placed in the duodenal limb near the ligament of Treitz. A 2-0 silk was used also outside of the Witzel technique to pexy this to the posterior abdominal wall. The tube was flushed and there was evidence of leakage. Its distal limb was threaded into the proximal enteroenterostomy. We then oversewed the duodenal stump using interrupting Vicryl 2-0 as well as the pancreatic margin. Two large Blake drains were placed from the right side near the anastomosis, duodenal stump and pancreatic staple line. All drains and feeding tubes were secured with multiple 2-0 silk suture. The viscera were then oriented and reinspected, and we irrigated with significant amounts of fluid and all effluent was removed. The patient was hemostatic. Lap, needle, and instrument counts were deemed correct x2 and then furthermore at the end of the case. Seprafilm was placed atop the viscera as it was oriented properly. The fascia was then closed using heavy PDS suture. The skin was stapled after irrigating subcutaneous tissues. Betadine ointment was placed to all drain sites and staples along with dry dressings. The patient appeared to tolerate the procedure. We explained all the aforementioned, including the extent of the surgery and the reason an extended lymphadenectomy had been performed.
