DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Gastroesophageal reflux disease refractory to medical management.
POSTOPERATIVE DIAGNOSIS: Gastroesophageal reflux disease refractory to medical management with diaphragmatic hernia.
OPERATION PERFORMED: Laparoscopic Nissen fundoplication and diaphragmatic hernia repair with porcine dermal implants.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was established. The patient was placed in the dorsal lithotomy position. OG tube was placed. Abdominal prep was carried out in a sterile fashion.
A supraumbilical incision was made. The Veress needle was used to acquire the peritoneal cavity, which was then inflated to 18 mmHg. A 5 mm clear bladeless trocar was piggybacked onto the 5 mm scope and driven directly into the abdominal cavity. The patient had stated that she had a lot of adhesions discovered with her cholecystectomy; however, we did not really appreciate any significant adhesions. The trocar was placed in the right upper quadrant, two in the left upper quadrant and one in the left mid abdomen. Liver retractor was then placed through the right upper quadrant port incision site lifting the left lobe of the liver up, with the patient in the steep reverse Trendelenburg position.
At that point, on viewing the diaphragm, it was immediately obvious that the patient had a large diaphragmatic hernia in addition to the acid reflux problem. The avascular plane of hepatogastric ligament was entered, skeletonized up to the right crux, which was then grasped and entered into the mediastinum, freed this crux from the esophagus observing both the anterior and posterior vagal branches and uncorking the esophagus and bringing the GE junction well down into the abdominal cavity for at least 3 cm.
Also, the left crux was separated from the esophagus. We then closed the posterior crux from left to right using 0 Ethibond sutures. We could still pass a 56 French bougie without difficulty. At that point, it was obvious that the diaphragmatic hernia must be repaired. A porcine dermal implant was brought up on the field. It was cut to fit the defect and placed into the peritoneal cavity and sutured into place circumferentially with 0 Ethibond sutures.
Finally, the greater curvature of the stomach was mobilized dividing the short gastrics from the stomach to the spleen forming a generous mobilization of the fundus, which was then pulled retroesophageal and folded to create a 360 degree wrap without any tension. We did a shoeshine maneuver to assure that there was not excess posterior fundus and a 360 wrap was carried out over the 56 French bougie from a wrap through esophagus back to wrap for a zone of 3 cm. Three sutures were used. Then, the bougie and Penroses were removed.
The wrap was tacked to the diaphragmatic hiatus with 0 Ethibond sutures and a wrap to stomach. Then, 0 Ethibond sutures were placed. These sutures were placed to prevent slippage into the mediastinum of the wrap or down as a collar onto the body of the stomach. CO2 and fluid was evacuated. The wounds were then closed in layers. At the completion of the procedure, sponge and needle counts were correct. Estimated blood loss was minimal. Sterile dressings were applied. The patient was removed from anesthetic and taken to the recovery room having tolerated the procedure well.
