VAC Change & Jejunostomy Tube

Operative Note Summary

Patient:  Kang Wei Ko
MRN:  2492702
Encounter Date:  Apr 26, 2012

Operative Note:
SURGEON NAME: Francesco Rubino, MD [6739R]
PROCEDURE DATE:04/26/2012
ADMIT DATE:04/26/2012
PREOPERATIVE DIAGNOSIS: Discontinuity of GI Anatomy and Open Abdomen (Vac) after Resection of Gastrojejunostomy for Endoluminal Bleed
POSTOPERATIVE DIAGNOSIS: Same

OPERATION: Abdominal Exploration; Feeding Jejunostomy + Vac Change
ATTENDING SURGEON: Francesco Rubino [6739R]
ATTENDING SURGEON: Alfons Pomp, MD
ASSISTANT SURGEON: Amanda Powers MD

The patient is a 35 yo male with morbid obesity, who underwent Roux en Y Gastric Bypass two months ago. He had two recurrent episodes of marginal ulcers with gastrointestinal bleeding successfully treated with endoscopic hemostasis. After a third recidivism of gastrointestinal bleeding last week with syncope he was admitted in critical conditions at another hospital in Queens. After a failed attempt to control GI bleed endoscopically, the patient underwent laparotomy with resection of gastro-jejunostomy and partial resection of gastric remnant. Gastrointestinal anatomy was left in discontinuity and the abdomen was left open due to edematous bowel.

The patient was transferred to our hospital and admitted to SICU with nasogastric tube, sedated and intubated. Patient's conditions and therapeutic plan have been discussed at length with his family, that consented for abdominal exploration, washout, possible feeding tube placement, possible spit fistula and possible reconstruction of gastrointestinal continuity.

PROCEDURE: The patient entered the operating room with orotracheal intubation. Following appropriate identification, he was placed in supine position on the operating table. Venodyne boots were applied. A surgical pause was performed in accordance with hospital regulations. Full general anesthesia was induced. The patient was prepped and draped in a supine position with appropriate padding and avoidance of hyper-extension of the extremities. Appropriate antibiotics were given intravenously.

Dr Stiles from thoracic surgery was consulted. An endoscopy was performed by Dr Stiles to evaluate the esophagus and gastric pouch. This revealed a well drained esophagus and gastric pouch with no accumulation of saliva. The gastric pouch was estimated to extend for approximately 2 com below the GE junction. Endoclips placed during previous endoscopy were noted. At this point the NG tube was slightly advanced down to the GE junction and it was decided that a spit fistula was not necessary to drain the stomach at this stage especially if anatomic reconstruction not feasible for the moment.

The wound vac was then removed and the abdominal cavity was explored. There was no evidence of abdominal collections, although adhesions were noted between omentum and abdominal wall and omentum and bowel loops. These adhesions were gently lysed using ligatures and sharp dissection. The bowel was still significantly edematous so that direct reconstruction of gastrointestinal anatomy was deemed not safe at this stage. For the same reason, direct closure of the abdominal wall was deemed not feasible nor safe at this stage. Exploration of the gastric remnant was performed to assess the degree of resection at previous surgery. The gastric remnant was viable and consisting of antrum and only a portion of the body of the stomach. Next, the intestinal anatomy was assessed and the biliary and Roux limbs were identified along with the jejuno-jejunostomy, which appeared intact.

At this point it was decided to place a deeding jejunostomy. The proximal end of the Roux limb was dissected free from its adhesions with omentum and a purse-string in 2-0 vicryl was placed on its anti-mesenteric border. Then a small enterotomy was performed at the center of the purse-string using ultrasound shears and a 18Fr Foley tube was insertetd into the jejunum. The purse-string was then tied around the tube, which was also secured within a tunnel of jejunum serosa for additional 3-4 cm using several Vicryl 2-0 stitches. The Roux-limb was then secured to the abdominal wall by two silk-2-0 stay stitches.

The bowel was examined and there were no obvious lesions but it was deemed too edematous yet to allow for safe closure of the abdominal wall.  Hemostasis was verified. With this being satisfactory, a KCL wound vac was used to cover the abdomen. The white foam base of the vac system was used first in direct contact with visceral content. A black foam overlay was then used above the white foam and therefore completely separated from exposed viscera. Sterile dressings were applied. Anesthesia was well tolerated. The patient was left intubated and accompanied by the surgical team to the recovery room. Estimated blood loss was approximately 50cc. Sponge, needle and instrument counts were reported correct to the surgeon.

Attestation: I was present and scrubbed during the entire procedure

Francesco Rubino, MD [6739R]
(Electronic signature on file)
_____________________________________________
Note electronically signed by  Francesco Rubino on Mon Apr 30, 2012 11:26 AM