DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Gunshot wound to the abdomen.
POSTOPERATIVE DIAGNOSES:
1. Gunshot wound to the abdomen.
2. Laceration of the gastric wall.
3. Descending colon mesenteric hematoma.
OPERATION PERFORMED:
1. Exploratory laparotomy.
2. Repair of gastric wall laceration.
3. Mobilization of the splenic flexure with evaluation of the descending colon mesentery.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
DRAINS: None.
SPECIMENS: None.
TUBES: NG tube placement confirmed by intraoperative palpation.
ESTIMATED BLOOD LOSS: 1100 mL.
URINE OUTPUT: 430 mL.
TOTAL FLUIDS: 4600 mL of crystalloid.
COMPLICATIONS: None.
POSTOPERATIVE CONDITION: Stable.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman, status post gunshot wound, brought to the emergency department where he was evaluated. It was determined that he had a gunshot wound to his left flank. He has one posterior in his back, just lateral to his spine, one gunshot in the right thigh, and a through-and-through injury from the right thigh, entering laterally and exiting medially. Initial evaluation revealed suspicion for penetration of the peritoneal cavity, and the patient was taken to the operative suite for intervention as described below.
DESCRIPTION OF OPERATION: Prior to the procedure, the patient was evaluated in the trauma bay. A FAST exam was positive for fluid. Plain films revealed a projectile presumably lodged in the patient’s liver. Therefore, operative intervention was indicated, and informed consent was obtained from the patient. Preoperative antibiotics were administered as well as tetanus. He was subsequently taken into the operating room, and general anesthesia was induced by the department of anesthesia. This was a somewhat difficult intubation but was successful.
At this point, the patient was prepped from his neck down to his knees and subsequently draped in a sterile fashion. After appropriate time-out, an incision was made from just below his xiphoid process curving to the left of the patient’s umbilicus and down towards the symphysis pubis. Dissection was carried down to the skin and subcutaneous tissues down to the level of anterior rectus fascia, which was incised with Bovie cauterization. The peritoneal cavity was entered. Minimal amount of bloody fluid was encountered. Stomach was massively dilated.
At this point in time, NG tube positioning was confirmed with the assistance of department of anesthesia, and the stomach was subsequently decompressed. There was blood noted in the patient’s left upper quadrant. Underwent systematic packing of all four quadrants, and at this point, began evaluating the area of the patient’s stomach and liver. We did notice a wound in the posterior-inferior aspect of the patient’s left lobe of the liver. This did not appear to be bleeding at this time. We also encountered an area along the lesser curvature of the stomach, which had some bleeding. We evaluated this area locally, did not identify a direct penetration into the gastric wall. This bleeding was oversewn with silk figure-of-eight sutures.
We then entered the lesser sac, evaluated the posterior aspect of the stomach. We did identify hematoma but no penetration of the stomach itself. At this point, we next turned our attention to the left upper quadrant. The spleen was felt to be intact, as did the patient’s diaphragm. There was hematoma laterally along the white line of Toldt on the patient’s left-hand side. At this point in time, we evaluated the rest of the patient’s abdomen. There appeared to be no direct injury to the right aspect of the liver. We did feel slightly raised area in the right lobe of the liver with a small amount of bruising, but no active bleeding or extravasation noted in this area. The right paracolic gutter was free of active extravasation as well as the patient’s pelvis.
At this point, we ran the small bowel from the ligament of Treitz down to the terminal ileum evaluating the mesentry closely. We did not identify any hematomas or lacerations. We did not identify any serosal or other form of bowel injury. At this point, we began inspecting the colon starting with the ascending colon. We did not notice any hematoma or injury to the ascending colon up along the hepatic flexure through the area of the transverse colon. There was some hematoma within this mesentry, which extended over to the area of the splenic flexure and descending colon.
At this point, we began mobilizing the patient’s descending colon. We opened along the white line of Toldt evacuating hematoma from the mesentry of the descending colon approximately 4 cm distal to the splenic flexure. We continued the mobilization until we took down the patient’s splenic flexure. Evaluation of the colon in this area revealed a small serosal injury as well as a defect through the patient’s mesentry. However, no active extravasation was noted at this time. The bowel itself appeared to be grossly viable.
At this point, we turned our attention to the area of the lesser curvature of the stomach. We reevaluated this area for hemostasis. At this point, we followed the pylorus around the first and second portions of the duodenum down to the level of the third portion of the duodenum anteriorly. We did not notice any hematoma in this area. We reevaluated the posterior aspect of the stomach to the lesser curvature again not identifying any injury to the stomach.
At this point, with coordination with the anesthesiologist, administered methylene blue into the NG tube and evaluated the area of the lesser curvature as well as the posterior aspect of the stomach. We did not notice any change in the color of the fluid in this area, and subsequently, we removed the pack from the lesser curvature and began oversewing the area of the gastric wall declaring this to be a non-full thickness injury, applying interrupted sutures so as to assure hemostasis.
At this point, we did notice a small rent in the mesentry of the transverse colon with no active bleeding. This was closed with a running 0 Vicryl suture. We then paid our attention back to the area of the previously evaluated area of the descending colon. The bowel again appeared to be viable. The small serosal tear was oversewn with interrupted Vicryl sutures, and the area was reevaluated for relative hemostasis. We irrigated the patient’s abdomen. We evaluated the area of the oversewing of the gastric area and applied FloSeal to this area allowing it to attach to the small area of injury to the liver.
At this point, we placed a piece of Surgicel in the left upper quadrant in the area of the mesenteric injury and the retroperitoneal hematoma. We allowed this to lie in its natural position, and after assuring an appropriate sponge count, we began closing the patient’s abdomen. This was done with #1 looped PDS, and subsequently upon closing the fascia, we irrigated the wound, closed the incision with staples. Sterile dressing was applied.
At this point, we rolled the patient, evaluated the wound on the posterior side on the back. This appeared to be, upon further investigation, more of a grease injury than a penetrating wound. At this point, dressing was placed over this area. The patient’s pulses were palpated at the conclusion of the case in the right leg due to the nature of gunshot wounds to this area. The patient did have distal pulses at this time. Therefore, he was transferred to the SICU and intubated in serious condition.
