PREOPERATIVE DIAGNOSIS: Small bowel obstruction, status post gastric bypass procedure.
POSTOPERATIVE DIAGNOSES: Small bowel obstruction, status post gastric bypass procedure. Few intraabdominal adhesions, no identifiable cause for small bowel obstruction.
OPERATION PERFORMED: Diagnostic laparoscopy, laparoscopic lysis of adhesions.
SURGEON: John Doe, MD
SEDATION: General endotracheal.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female who presented to the emergency room complaining of nausea for the last four to five days and worsening onset of abdominal pain this evening with emesis. The patient described having pain across her upper abdomen. The patient’s physical examination revealed upper abdominal tenderness. The patient underwent a CT scan, which showed a proximal small bowel obstruction in the region of the distal jejunum, proximal ileum. There is noted to be dilated distal jejunum filled with stool, which extended to the left upper quadrant area. Based on the patient’s clinical picture and CT findings, it was recommended she undergo a diagnostic laparoscopy for small bowel obstruction with the possibility of an exploratory laparotomy. The procedure, including risks and potential complications, were discussed with the patient. The patient understood and agrees with the plan.
OPERATIVE FINDINGS: There was a moderate amount of acidic fluid within the abdominal cavity. The patient had dilated bowel involving the Roux, the enteroenterostomy, the bilateral pancreatic limb, as well as the common channel. There was dilated bowel throughout the entire small bowel from the Roux limb to the distal small bowel with areas of normal caliber bowel. The findings were more consistent with an ileus versus a small bowel obstruction. There are a few intraabdominal adhesions of omentum on the abdominal wall, which did not appear to have involved the small intestine. There were no identifiable internal hernias. The enteroenterostomy closure as well as Peterson space and transverse mesocolon closures were all intact. All the bowel was viable.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and laid in supine position and leads for monitors applied. The patient was intubated, and general anesthesia was achieved. The patient’s abdomen was prepped and draped in sterile fashion.
An incision was made in the umbilicus, the Veress needle carefully placed. Next, the pneumoperitoneum was established, and a 5 mm blade with trocar was placed through the umbilicus. Diagnostic laparoscopy was performed with the findings as above.
Additional 11 and 5 mm bladeless trocars were placed lateral to the right of the abdomen and then additional 5 mm bladeless trocars were placed lateral to this in left lower quadrant area. Diagnostic laparoscopy was performed with the findings as above. There were a few adhesions of omentum on the abdominal wall, which were taken down bluntly. There was a moderate amount of acidic fluid in the abdominal cavity.
Upon initial diagnostic laparoscopy, the findings were consistent with a small bowel obstruction. The bowel was run from the Roux limb all the way to the common channel. The biliopancreatic area was examined. The native stomach did not appear to be significantly dilated. The small bowel was run from the Roux limb all the way to the common channel. All the areas for potential internal hernia were examined. There was no evidence of any internal hernias.
Small bowel was run from the common channel all the way to the ileocecal valve. There was some dilated bowel, which would go into normal caliber bowel, which then again would be going into dilate bowel. This was run all the way to the ileocecal valve. It was also noted that there was air within the colon. The small bowel was then again run from the ileocecal valve back up to the common channel. Again, there was no evidence of a small bowel obstruction secondary to a mechanical cause such as adhesion or internal hernia.
Satisfied that the entire small bowel had been run from the common channel all the way to the ileocecal valve and also involving the Roux, it was felt that there was no evidence of mechanical obstruction. The procedure was then completed by releasing the pneumoperitoneum. All the trocars were removed. There was no bleeding noted from the trocar sites. All the ports were infiltrated with 0.5% Marcaine with epinephrine. The skin was closed using 4-0 Vicryl in subcuticular fashion. Steri-Strips were applied and a sterile dressing.
The plan would be to further work this patient up with further x-rays and possibly a small bowel follow-through study. The above findings were discussed with the patient’s parents after the surgery.
