VAC Change & Abdomen Closure

Operative Note Summary

Patient:  Kang Wei Ko
MRN:  2492702
Encounter Date:  May 02, 2012

Operative Note:
SURGEON NAME: Francesco Rubino, MD [6739R]
PROCEDURE DATE:05/02/2012
ADMIT DATE:05/02/2012

PREOPERATIVE DIAGNOSIS: Discontinuity of GI Anatomy and Open Abdomen (Wound Vac) after Resection of Gastrojejunostomy for Endoluminal Bleed
POSTOPERATIVE DIAGNOSIS: Same

OPERATION: Abdominal Exploration and Washout; Closure of Abdomen with Alloderm + Wound Vac Placement + Esophageal Endoscopy and Cervical Esophagostomy Tube Placement

ATTENDING SURGEON: Francesco Rubino [6739R]
ATTENDING SURGEON: Brendon Stiles, 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. Last week the patient underwent abdominal exploration and washout with placement of feeding jejunostomy. The abdomen was left open due to significant edema of the viscera.

Patient's conditions and therapeutic plan have been discussed at length with his family, that consented for abdominal exploration, washout, abdominal closure, cervical esophagostomy, 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 performed the left cervical esophagostomy with a 18F nasogastric tube on the left side of the esophagus (see his op note for details).

After removal of the Vac the abdominal cavity was washed copiously with saline. The position of the Jejunostomy tube was checked and was found to be securely in place in the Roux- limb. The JP drain was removed. The abdominal fascia was then separated from the subcutaneous tissue in a circumferential fashion leaving an edge of at least 2 cm. At this point the abdominal defect was evaluated and it was determined that it was not possible to close the abdominal wall safely. At this point the abdominal wall defect was measured. Then two pieces of Alloderm were assembled together appropriately to obtain a 32x20 cm mesh. This was secured to the fascial edges circumferentially with a running #1 Prolene suture. Then, white foam was placed against the alloderm and black foam layer was placedon top of the white foam. A  KCI Vac was placed under suction to -100mmHg.The J tube was left to gravity.

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.

I was present during the entire procedure.

Francesco Rubino, MD [6739R]
(Electronic signature on file)

_____________________________________________
Note electronically signed by Francesco Rubino on Fri May 25, 2012  5:23 PM