DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Small bowel obstruction, status post gastric bypass procedure.
POSTOPERATIVE DIAGNOSIS:
Small bowel obstruction secondary to internal hernia secondary to Petersen’s space hernia.
OPERATION PERFORMED:
1. Diagnostic laparoscopy for small bowel obstruction.
2. Laparoscopic reduction and repair of internal hernia, Petersen’s space hernia.
3. Laparoscopic lysis of adhesions.
SURGEON: John Doe, MD
ANESTHESIA: General with endotracheal intubation.
INDICATIONS FOR OPERATION: This is a (XX)-year-old gentleman who had undergone a previous laparoscopic Roux-en-Y gastric bypass procedure. The patient lost significant amount of weight. The patient recently developed abdominal pain, and he presented to the emergency room. CAT scan showed evidence for a small bowel obstruction. The patient was presumed to have evidence for small bowel obstruction secondary to internal hernia or adhesions, and it was recommended that he undergo diagnostic laparoscopy and possible exploratory laparotomy. The procedure including risks, benefits, complications such as bleeding, infection, enterotomy, the possible need for exploratory laparotomy, among others was discussed with the patient. The patient understood and consented to proceed with the procedure.
OPERATIVE FINDINGS: The patient’s Roux limb was dilated. The patient’s excluded stomach was dilated. The patient had evidence for an internal hernia secondary to a Petersen’s space hernia from the ligament of Treitz to enteroenterostomy and common and Roux limb. There were also some adhesions involved between the enteroenterostomy and some adjacent mesentery. All the bowel was viable.
DESCRIPTION OF OPERATION: The patient was brought into the operating room, laid in supine position, and appropriate monitors were applied. The patient was intubated and general anesthesia was achieved. The patient’s abdomen was prepped and draped in sterile fashion. A Veress needle was placed in the left upper quadrant. Pneumoperitoneum was established.
An 11 mm bladeless trocar was placed in the right upper quadrant area with laparoscope in place. Diagnostic laparoscopy was performed with findings as above. An additional 11 mm bladeless trocar was placed in the area just above the umbilicus. Two 5 mm bladeless trocars were placed in the lateral left aspect of the abdominal wall and one in the right upper quadrant. The patient was placed in slight reverse Trendelenburg position. The bowel was explored with the findings as above.
The patient was noted to have Petersen’s space hernia. Petersen’s space hernia was reduced. Once this was reduced, the Roux limb could still not be totally reduced, and there were two adhesions between the enteroenterostomy and the adjacent mesentery, which had caught the Roux limb and prevented it from being completely reduced. These two adhesions were divided under direct visualization, not dissecting the area underneath the small bowel.
Once this was done, all the bowel could be run and visualized in its appropriate orientation. The Roux limb was run from the transverse mesocolon all the way to the enteroenterostomy. The ligament of Treitz was run from the ligament of Treitz to the enteroenterostomy. The common channel was run to the ileocecal valve.
Note, the Petersen’s space hernia involved the biliopancreatic limb of the bowel, portion of the Roux limb, as well as common channel. This was being pulled from the ligament of Treitz area all the way around into the lesser sac and to the other side of Petersen’s space. Once the adhesions were taken down, the bowel was all run in its proper orientation. The bowel was then inspected and all the bowel was viable. There were no enterotomies encountered. The diagnostic laparoscopy revealed no abnormal fluid collection noted. No active bleeding noted.
Next, the gap in the transverse mesocolon was completely closed using interrupted U clips. There was no impingement on the lumen of the Roux limb. Next, Petersen’s space hernia was completely closed using interrupted U clips. Once satisfied, these were completely closed. The enteroenterostomy area was inspected. This area was scarred in and completely closed. The enteroenterostomy was widely patent.
Satisfied with this, the procedure was then completed by performing diagnostic laparoscopy. All the bowel was viable. The pneumoperitoneum was released. The diagnostic laparoscopy was performed. There was no abnormal fluid collection noted. There was no active bleeding noted. The trocars were removed. The fascia at the 11 mm trocar site was closed using 0 Vicryl sutures. All the wounds were infiltrated with 0.5% Marcaine with epinephrine. Skin was closed with 4-0 Vicryl in subcuticular fashion. Steri-Strips were applied and a sterile dressing. The patient tolerated the procedure without any complications. Blood loss was less than 15 mL. All instrument and sponge counts were reported correct x2.
