DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Paraesophageal hernia.
POSTOPERATIVE DIAGNOSIS: Paraesophageal hernia.
OPERATION PERFORMED: Laparoscopic converted to open paraesophageal hernia repair.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia with endotracheal tube intubation.
SPECIMEN: None.
COMPLICATIONS: None.
DRAINS: None.
ESTIMATED BLOOD LOSS: Approximately 200 mL.
INTRAOPERATIVE FINDINGS: There was a very large paraesophageal hernia. No complications occurred intraoperatively. During the course of our dissection and after we had started to perform crural closure, we noticed that there was separation of the right crus, and at this point, we converted the laparoscopic procedure to an open procedure. Examination of the stomach revealed no injury or signs of perforation. No injury occurred to the liver. At the conclusion of the procedure, once it was converted to an open approach, crural closure was performed and shown to be intact over a 54 French bougie. A nasogastric tube was replaced for the bougie at the end of the case and laid comfortably within the stomach. Our area of dissection along with a hernia sac was shown to be hemostatic, and the gastroesophageal junction was below the diaphragm at the end of the case.
DESCRIPTION OF OPERATION: The patient was taken into the operating room and placed in a supine position. Bilateral lower extremity athrombic boots were placed. General anesthesia was induced. Nasogastric tube along with a Foley catheter were placed. The patient’s abdomen was then sterilely prepped and draped in the standard surgical fashion. The Hasson technique was utilized to gain entry into the abdominal cavity in the midline between the xiphoid and umbilicus. The peritoneal cavity was entered. A pneumoperitoneum was then created to 250 mmHg. The patient tolerated the insufflation well. After this occurred, examination at the esophageal hiatus did show a very large paraesophageal hernia. Once this was established, we then replaced our additional working ports. All of these ports were viewed under direct vision, and no bowel injuries occurred. In addition to this, prior to working on the dissection of the paraesophageal hernia, we were able to mobilize and retract omental fat with the use of endoloop sutures x2.
We were then able to make an incision along the peritoneum overlying the abdominal esophagus, and we were able to extend this over both the left and the right pleura with the use of a Harmonic scalpel. Once this occurred, we were able to then gently mobilize the hernia sac out of the mediastinum and back into the abdominal cavity from a cephalad to a caudal direction. We then created a window through a portion of the lesser curvature of the stomach along the liver, which was able then to eventually expose the right crus nicely. The hernia sac was then dissected also off the right crus, extending along the paraesophageal ligament to the left crus. There was not much hernia sac present on the left crus, and we could easily identify this structure.
During the course of this dissection, it should be noted that we did have a 50 French bougie placed down past through the patient’s stomach to allow us to again easily identify the esophagus during the course of our dissection and visualization of the left and right crus. Once this was completed, we then took an auto suturing device and proceeded to close the esophageal hiatus. We started in a cephalad direction and placed three sutures from the left to the right crus. We were progressing well, but during the course of this noticed that there was a separation of the right crus that had created a rent, and at this time, we felt could not adequately close the esophageal hiatus and allow us to be able to place the gastroesophageal junction from the mediastinum back into the abdominal cavity.
Therefore, we decided to proceed with an open procedure. We then proceeded to make a vertical midline incision from the xiphoid to the site where a previous trocar had been placed within the midline. This incision was then deepened through the subcutaneous tissues, and hemostasis was achieved with electrocautery. The linea alba was identified and incised and the peritoneal cavity entered. A retracting device was then placed to allow adequate exposure of the esophageal hiatus. Once this was exposed, some additional adhesions were then lysed sharply using Bovie electrocautery. The previous three sutures from the auto suturing device could easily be seen and shown to be intact and reinforcing the crura quite well. However, we continued to use some further blunt dissection to expose the right crus and were able to tell where the defect had slightly occurred in the cephalad region of this area.
At this time, we felt that we would be able to take some additional bites to reinforce our esophageal hiatus. We then proceeded to go ahead and take two additional stitches of 2-0 silk suture in the topmost portion and close the crura. We were able to perform this over a 54 French bougie, and after completion of the closure, the GE junction was now within the abdominal cavity in addition with the hernia sac being totally reduced. The lesser along with greater curvature of the stomach along the body and fundus were visualized, and there was no perforation from the previous laparoscopic procedure. Hemostasis was checked and shown to be intact. The abdominal cavity was then copiously irrigated with warm normal saline. The 54 French bougie was then removed, and a nasogastric tube was placed within the stomach, easily being palpated with Anesthesia’s assistance.
Once this was completed, the retracting device was then removed. On-Q pain pump catheters were then placed on each side of our midline incision. The anterior fascia was then reapproximated with a running 0 Prolene suture. The subcutaneous tissues were irrigated. The subcutaneous tissues were closed with a running 3-0 Vicryl suture. The skin incision was then closed with skin staples. A dry sterile dressing was placed. The On-Q pain system was then attached to the two accompanying catheters. This was placed to allow for adequate postoperative pain control. The catheter was coiled and anchored with application of Steri-Strips. All instrument, sponge and needle counts were correct at the end of the case. The patient was then awoken from anesthesia and transported to the recovery room in stable condition.
