Surgical VAC Change

Operative Note Summary

Patient:  Kang Wei Ko
MRN:  2492702
Encounter Date:  Oct 19, 2012

Operative Note:
PT NAME:  KANG WEI KO
MRN:  100554653

SURGEON MD#:
SURGEON NAME:  Alfons Pomp, MD [PO089]

PROCEDURE DATE:  10/19/2012

ADMIT DATE: 9/21/2012
PREOPERATIVE DIAGNOSIS: Open, infected wound with (likely) enterocutaneous fistula
POSTOPERATIVE DIAGNOSIS: Same
OPERATION: Dressing change
ATTENDING SURGEON: Alfons Pomp, MD [PO089]
ASSISTANT SURGEON: Jennifer Murphy MD, Mike Chervonski MD

The patient is a 35 yo male with history of morbid obesity and laparoscopic Roux-en-Y Gastric Bypass in March 2012. He required emergency laparotomy and revision of gastrojejunostomy at an outside hospital in May 2012 where he underwent laparotomy with resection of gastro-jejunostomy and partial resection of gastric remnant. Gastrointestinal anatomy was left in discontinuity  After an prolonged period of recovery and significant weight loss on 9/21/2012 he underwent esophagogastric-jejunal anastomosis and reconstruction of Roux-en-Y gastric bypass and advancement flaps to close the abdomen: the wound was left open. The patient has a wound "VAC" in place and we obtained consent to change the VAC device and debride his wound while under anesthesia.

PROCEDURE: The patient was in his monitored bed on 8 North (the operating room was not available)  Following appropriate identification, anesthesia
surveillance was "induced" (without orotracheal intubation).  No antibiotics
were considered necessary.

The "VAC" dressing was removed and  the operative site was examined and
hemostasis was verified. The wound appeared clean without purulence and with good granulation tissue. The "VAC" dressing was re-applied (white and black foam). Anesthesia was well tolerated. Estimated blood loss was < 25cc. Sponge, needle and instrument counts were not judged necessary.

I was present during the entire procedure.

Alfons Pomp, MD, FACS

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Note electronically signed by  Alfons Pomp on Mon Oct 22, 2012  8:28 AM