DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Adenocarcinoma of the stomach, extensive.
POSTOPERATIVE DIAGNOSIS: Adenocarcinoma of the stomach, extensive.
OPERATIONS PERFORMED:
1. Tube jejunostomy.
2. Port-A-Cath.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic male who recently has developed nausea, weight loss, and difficulty eating. An EGD of his abdomen demonstrated a large ulcerated mass along the lesser curvature. CT scanning of his abdomen demonstrated a significant extragastric component of this mass, which extended from the region of the gastroesophageal junction to the pylorus. The lesion also was thought to involve surrounding organs, including liver and probable pancrease. Because of the extensive nature of this lesion, it was elected to first treat him with a preoperative neoadjuvant chemotherapy and radiation therapy approach. It is hoped that he will be resectable after this. He was brought to the operating room for placement of a Port-A-Cath and a feeding jejunostomy to facilitate his antitumor therapy.
OPERATIVE FINDINGS: It was possible to examine his abdomen through the small incision used to place his jejunostomy. No evidence of metastatic disease in the peritoneum could be identified. No omental nodules were palpable. The lesion could be palpated running along the lesser curvature of the stomach. The region of the greater curvature seemed spared of tumor. The tumor mass seemed adherent to the tail of the pancreas. The overall impression of the lesion was that it was perhaps less extensive than the CT scan suggested. It is hoped that following the neoadjuvant treatment that he can be resected with curative intent.
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 induced. The patient’s chest and entire abdomen were then prepped with DuraPrep. Sterile drapes were applied. He was given Ancef and Flagyl intravenously. Attention was first turned to the region of the Port-A-Cath.
Standard left subclavian venipuncture was performed without difficulty. A guidewire was threaded into the inferior vena cava. Its position was confirmed fluoroscopically. An incision was then made adjacent to the guidewire and taken down to the fascia of the pectoralis major muscle. A pocket was dissected for a port at this level. The dilating system and sheath were then passed over the guidewire. The sheath was used to allow the catheter to be placed in the right atrium. The sheath was then peeled away. Fluoroscopy was used to first be sure that the guidewire was in the inferior vena cava. It was then used to help position the tip of the catheter just at the junction of the SVC and right atrium. This was done with the use of injected contrast.
After the tip was carefully placed, the catheter was sutured in place with a 2-0 silk ligature. The catheter was then cut to the appropriate length and attached to the port. The port was placed in the pocket. Three sutures of 2-0 black silk were used around the rim of the port and sutured into the fascia. The catheter was allowed to lie in a nice curve. Following this, the wound was closed with interrupted 3-0 Vicryl subcutaneous sutures, running 5-0 PDS subcuticular in the skin, and Dermabond. The port was accessed with a Huber needle. Good blood return was obtained, and it was flushed and locked. A dressing of gauze and Tegaderm was placed.
Attention was then turned to the abdomen. A small midline incision was made and taken down into the peritoneal cavity. The exploration noted above was carried out. The ligament of Treitz was identified. The jejunum approximately 30 cm distal to this was selected for the port. Small pursestring suture of 3-0 silk was placed in the antimesenteric border. A 14-French red rubber catheter then had the tip cut off and extra holes placed in it. This was pulled into the abdomen through a stab wound. A hole was made in the bowel through the pursestring. The catheter was inserted into the bowel through the pursestring and threaded approximately 15 cm distally. The pursestring suture was tied down around the catheter. Five sutures were then placed between the bowel and the peritoneum surrounding the entrance of the catheter into the abdominal cavity. These were tied down in standard fashion. This resulted in good closure of the area around the catheter and no evidence of potential area for leak.
Following this, the wound was closed. Layer of 0 Vicryl was used to close the peritoneum, 0 Vicryl pop-offs were used to close the fascia in figure-of-eight fashion, and the skin was closed with interrupted 3-0 Vicryl subcutaneous sutures, running 5-0 PDS subcuticular to the skin. A Dermabond dressing was applied. The patient tolerated this well and was returned to the recovery room in satisfactory condition.
