DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Gastrocutaneous fistula, status post PEG removal.
POSTOPERATIVE DIAGNOSIS: Gastrocutaneous fistula, status post PEG removal.
OPERATION PERFORMED:
1. Laparoscopic repair of gastrocutaneous fistula.
2. Reconstruction of abdominal wall defect with AlloDerm and mesh.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMENS: Stomach.
INDICATION FOR OPERATION: This is a (XX)-year-old lady with breast cancer who had a PEG tube, which was dislodged and finally removed. She has had persistent gastric leak and we recommended surgical repair. The risks, benefits and alternatives were discussed with her, and she has consented for surgery.
DESCRIPTION OF OPERATION: The patient was brought to the OR and placed supine on the operating table. After undergoing anesthesia, the abdomen was prepped and draped in sterile fashion using chlorhexidine prep. A 5 mm Optiview trocar was placed in the lower midline. The abdomen was insufflated.
Two right-sided trocars, a 12 mm and a 5 mm trocar, were placed under direct visualization. Some omentum was taken off the anterior abdominal wall, and endoscopic GIA 60 mm stapler was used in two bites to come across the gastric portion of the greater curvature of the stomach, which was tacked to the intra-abdominal wall, which allowed the stomach to drop back down. The remnant of stomach, which was stuck to the anterior abdominal wall, was taken down with scissors, placed in a bag and removed through the 12 mm trocar site and then reinserted the trocar. There was a criss-crossing of the staple lines on the greater curvature of the stomach, and we elected to oversew this laparoscopically with 2-0 silk Lemberts. The entire suture line was oversewn with interrupted 2-0 silk Lemberts.
The body of the stomach appeared narrow but adequate due to the nature of her stapling. We do not think she should have any issues with this. The gastric defect was somewhat large where her PEG tube side had come out and enlarged the defect in the anterior abdominal wall, which necessitated repair. Before doing this, we removed our three laparoscopic trocars and closed the skin with 4-0 Monocryl and Steri-Strips.
We ellipsed out the subcutaneous fistula tunnel, which had some purulent necrotic fat. We realized the defect in the abdominal wall was too large to close primarily, and she has had a TRAM on that side, and her rectus muscle is now gone. We loosely approximated the defect with interrupted 0 Vicryls and then repaired it with onlay of AlloDerm mesh. We copiously irrigated and debrided out subcutaneous tissues. A 10 mm round JP drain was placed on top of the AlloDerm mesh. The 2-0 Vicryls and nylons were used to close the skin. A dressing was applied. The patient was awakened and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.
