Reconstruction of Roux-en-Y Gastric Bypass

Operative Note Summary

Patient:  Kang Wei Ko

MRN:  2492702

Encounter Date:  Sep 21, 2012

Operative Note:

PT NAME:  KANG WEI KO

MRN:  100554653

SURGEON NAME: Francesco Rubino, MD [6739R]

PROCEDURE DATE: 09/21/2012

ADMIT DATE: 09/21/2012

PREOPERATIVE DIAGNOSIS: S/P  Resection of gastrojejunostomy due to gastric ulcer beed after gastric bypass surgery, s/p end jejunostomy

POSTOPERATIVE DIAGNOSIS: Same

OPERATION: Esophagogastric-jejunal anastomosis and reconstruction of Roux-en-Y gastric bypass, extensive lysis of adhesions, feeding jejunostomy, closure of end jejunostomy, closure of iatrogenic enterotomy, closure of mesenteric defect to repair internal hernia, advancement flaps to close the abdomen, intra-operative upper endoscopy

ATTENDING SURGEON: Francesco Rubino, MD [6739R]

ATTENDING SURGEON: Alfons Pomp, MD [PO089]

ATTENDING SURGEON: Brendon Stiles

ASSISTANT SURGEON: Lindsay Cohen MD, Matthew Bott, MD

The patient is a 35 yo male with history of morbid obesity and laparoscopic Roux en Y Gastric Bypass in March 2012. Postoperatively he had recurrent episodes of marginal ulcers with gastrointestinal bleeding. He  required emergency laparotomy and revision of gastrojejunostomy at an outside hospital in May 2012. At the time he 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. He was then transferred to WCMC where he underwent abdominal exploration and washout with placement of feeding jejunostomy, cervical esophagostomy and closure of abdominal wall with Alloderm. After an  Prolonged period of recovery and significant weight loss (>100 lbs) the patient has been scheduled for reconstruction of gastrointestinal anatomy. Pre-operative consent was obtained.Given the extreme complexity and technical difficulty of the case, Dr. Pomp assisted throughout this 7 hour procedure and Dr Stiles assisted intermittently  throughout the procedure but was present during the gastroesophageal dissection and anastomosis (principle parts of the procedure).

PROCEDURE: The patient entered the operating room. 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 with orotracheal intubation. A Foley catheter was placed in the usual sterile fashion. 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.

An incision was carried down on the midline, in the lower abdominal area. With careful dissection the abdominal cavity was entered under direct vision and the laparotomy eventually extended cephalad to the xyphoid process. There were extensive adhesions between the small bowel and the abdominal wall requiring adhesiolysis. The adhesions were taken down using a lengthy and tedious dissection of over 3 hours (44005) with sharp and blunt instruments in order to entirely free the small bowel and allow mobilization of the jejunostomy. The jejunostomy was taken down under the jejunostomy using a linear stapler. The entire small bowel was examined, starting from the ileo-cecal valve and moving cephalad toward the ligament of Treitz. This maneuver allowed identification of the jejuno-jenunostomy and clear distinction of the biliary, alimentary and common limbs of the RY-anatomy. Dissection of bowel-to-bowel adhesions and intermesenteric adhesions was then performed to lengthen the alimentary limb and obtain its adequate mobilization for anastomosis. There was one small (2mm) enterotomy which was closed with 2 layers using 2-0 Vicryl.(44602) Next, the upper abdominal area was exposed using a Omnitrac retractor. There were extensive adhesions between the liver and the abdominal wall, the liver and the gastric remnant and the transverse colon and liver. This again required extensive adhesiolysis.Dissection of adhesions allowed clear identification of gastric remnant and transverse colon with its splenic flexure located high up in the left hypochondrium. The dissection also revealed a significant small bowel herniation through the tranverse mesocolon. The herniated bowel was reduced in the submesocolic space and the mesocolic defect closed with running suture (silk 2-0) (44050).

Next the left lobe of the liver was partially mobilized and dissected from the upper gastric pouch. This was clearly identified with the assistance of intraoperative esophago-gastroscopy (Dr Stiles). The left and posterior aspects of the gastric pouch were mobilized sufficiently to allow a gastro-jejunostomy. At this point, with the endoscope in the gastric pouch, a small gastrostomy was performed at the posterior lower part of the gastric pouch. A snare was pushed through the endoscope and passed through the gastrotomy into the abdominal cavity. A long silk suture was anchored to the snare and pulled all the way up to through the mouth and connected to the tip of an orogastric tube armed with the anvil of an EEA 25. This was passed by the anesthesiologist through the mouth into the proximal gastric pouch. The orogastric tube was removed, leaving the anvil in place. Two sutures (vicryl 2-0) were placed on both sides of the gastrotomy to further secure the anvil in place.

Following this, the staples on the distal jejunum were now removed to permit the introduction into the bowel of an EEA- 25. This was inserted for about 5 cm and the spike of the EEA was pushed through the anti-mesenteric side of the small bowel. The male and female parts of the EEA were drawn together to create an antecolic, antegastric, esophagogastro-jejunostomy (43340). The EEA was fired and removed. This was accomplished without problem. The anastomosis was without undue tension. The opening in the small bowel was closed with a GIA stapler (white cartridge). Several 2-0 Vicryl sutures were placed between the musculoserosa of the gastric pouch and the jejunum to complement the anastomosis on its right and left sides.

Another endoscopy performed to verify the integrity of the G-J from the inside. The anastomosis appeared adequate and the endoscope was advanced in the efferent jejunal loop. Then the bowel was occluded and an air-bubble test was performed. The test revealed no leaks at the gastric suture line, at the anastomosis, or at the closure of small bowel. This was entirely satisfactory. A JP 7fr drain was positioned along the gastro-jejunostomy, and secured to the right abdominal wall by a  silk suture.

The end jejunostomy was taken down by circumferentially dissecting out the mucosa-skin junction with electrocautery and then subcutaneously and then freeing this up from the fascia. The fascia was then approximated with #1 Vicryl. The skin was left open.

Next, a jejunostomy was performed (44015) on the initial part of the common limb, just caudal to the jejuno-jejunostomy. To do so, a Vicryl 2-0 purse string was placed and an enterotomy performed using ultrasound shears. A 22-Fr T-tube was then inserted in the bowel, the purse string suture was cinched and tied and the jejunostomy secured to the parietal peritoneum in the right hypochondrium with 2-0 silk sutures in the cardinal positions

The bowel was examined again and there were no obvious lesions. Hemostasis was verified.

With this being satisfactory, just enough of the abdominal fascial flaps were advanced on top of the rectus fascia (under the skin and fascia) to and incision at the junction with the obliques bilaterally; this was a dissection area of about 200 square cm (14301, 14302 X 5).  This allowed appropriate closure of the abdominal wall without undue tension. The abdominal fascia was then closed using #1 Maxon double loop sutures. At this point the wound was heavily irrigated and the skin was left open given the contaminated nature of this operation. Sterile dressings were applied. Anesthesia was well tolerated. The patient was left intubated on the table and accompanied by the surgical team to the recovery room. The lysis of adhesions took more than 3 hours overall.  The entire case took 7 hours and 15 min. Estimated blood loss was approximately 1300 cc., one unit of PRBC was transfused intraoperatively. 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]
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Note electronically signed by Francesco Rubino on Wed Sep 26, 2012  1:36 PM

Attestation: I was present and scrubbed during the entire procedure.

Alfons Pomp MD

_____________________________________________

Note electronically signed by Alfons Pomp on Mon Sep 24, 2012  4:31 PM