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General Surgery

PROCEDURE: Appendectomy

With the patient in the supine position and after general anesthesia had been achieved, a Rockey-Davis incision was made at the McBurney point and deepened through subcutaneous tissue. Using electrocautery, the bleeders were cauterized. The external oblique aponeurosis was incised along the length of its fibers using the Metzenbaum scissors. The internal oblique and transverse abdominal muscles were split bluntly using Kelly clamps. The peritoneum was grasped with 2 Kelly clamps, raised and nicked with a scalpel, immediately after which pus came through the incision in the peritoneum. The pus was cultured. The incision of the peritoneum was completed with Metzenbaum scissors.

After that had been achieved, we identified the appendix, which was grasped with 2 Babcock clamps and raised into the wound. Also, another Babcock grasped the cecum and was mobilized toward the wound. The mesoappendix was serially clamped, divided and ligated with 2-0 chromic. The appendiceal base was clamped with straight hemostats and was ligated twice with 0 chromic. The appendix was amputated, and the appendiceal stump was cauterized with electrocautery.

The abdominal cavity was copiously irrigated with kanamycin solution. The wound was closed in layers. The peritoneum was closed in a continuous fashion using 2-0 Maxon. The transverse abdominal muscles and internal oblique were closed in an interrupted fashion using 2-0 Maxon. The external oblique aponeurosis was closed in a continuous fashion using 2-0 Maxon and the skin was closed with staples.

PROCEDURE: Laparotomy, Right Hemicolectomy

With the patient in the supine position, after successful induction of general anesthesia with intubation, the operative field was prepped with Betadine and draped in a sterile manner.

A midline incision was made through a previous lower abdominal midline incision. The abdomen was entered. The adhesions were lysed and exploration was carried out with the above findings noted.

The right colon was mobilized from the right colic gutter with the terminal ileum, the hepatic flexure and the right transverse colon. The duodenum was protected and the ureter was protected. A wedge of right colonic mesentery was resected with the colon. The vessels were ligated with 2-0 silks between clamps. Thereafter, the lesion was resected with a short segment of ileum and a short segment of the transverse colon and removed to pathology.

A side-to-side anastomosis was done with 16-mm GIA and the edges were closed with 3.5, TA-55 Auto Sutures and reinforcement sutures with lubricated 3-0 silk. The mesenteric gap was closed with continuous running sutures of 2-0 chromic catgut. Hemostasis was checked and satisfactory. The abdomen was irrigated clean with normal saline. Omentum was replaced over the small bowel and the abdomen was closed. The peritoneum was closed with continuous running suture of 0 Maxon. The linea alba was closed with continuous running sutures of 2-0 plain Prolene sutures. Subcutaneous tissue closed with 2-0 plain catgut. The skin was closed with skin clips.

OPERATIVE PROCEDURE: Excisional Biopsy Mass Right Breast

FINDINGS: At the time of surgery, a firm mass measuring approximately 8 mm in diameter was encountered and removed. Frozen section confirmed the presence of a fibroadenoma.

PROCEDURE: After prepping and draping the patient in the usual manner, intravenous sedation was administered by the anesthesiologist. Local anesthesia consisting of 1% Xylocaine with adrenaline 1:100,000 was infiltrated in the 6 o'clock position of the right breast.

A curvilinear incision was made and deepened through the subcutaneous tissue, identifying the palpable nodule. The area was grasped with an Adair clamp. Using sharp dissection, a sphere of tissue measuring approximately 1.6 cm in diameter was excised. While still in situ, it was identified with a single suture in the 12 o'clock position and 2 sutures in the 9 o'clock position. Hemostasis was secured using the coagulating current of the electrocautery. The wound was then irrigated with a sterile water solution.

Interrupted sutures of undyed 4-0 Polysorb were used to approximate the subcutaneous tissue, with a similar undyed 4-0 Polysorb suture being used as a plastic subcuticular closure. Steri-Strips and a dry sterile dressing were applied.

PROCEDURE: Breast Biopsy With Needle Localization

The patient had the localization done in Radiology and was then brought to the operating room and placed supine on the table. The area was washed, prepped and draped.

After adequate sedation was given by the anesthesiologist, 1% plain lidocaine was infiltrated into the area. After adequate local anesthesia was achieved, the incision was made using a #15 blade along the shaft of the needle. The incision was deepened using blunt and sharp dissection. The suspected lesion along with a normal piece of breast tissue was excised and sent to Radiology, where a radiograph of the specimen confirmed the presence of the nodule. This was then sent to the pathologist fresh.

The wound was thoroughly irrigated with normal saline. Hemostasis secured and the wound repaired in 2 layers, the deeper with interrupted 4-0 Monocryl sutures. The skin was approximated using interrupted 6-0 Dermalon sutures.

PROCEDURE: Laparoscopic Cholecystectomy

Under general endotracheal anesthesia, the patient's abdomen was prepped with Betadine and suitably draped.

An infraumbilical incision was made through skin and subcutaneous tissue. Hemostasis was achieved with the Bovie cautery. The rectus exposed, cut transversely, the posterior sheath incised, and the peritoneal cavity entered at the point where adhesions were noted from previous laparoscopic procedures. Using blunt dissection, the adhesions were taken off the peritoneum at the point of entry, and the blunt port trocar was introduced directly into the abdominal cavity, sutures of 1-0 Maxon taken to either side to minimize gas leak. The CO2 insufflator was connected to the trocar, and the abdomen was inflated with 15 mm Hg pressure with carbon dioxide. The 30-degree, angled, 10-mm laparoscope was then introduced through the trocar and the abdominal cavity examined.

The gallbladder was subacutely inflamed with adhesions to surrounding viscera, which were easily swept down. However, the wall was quite thickened, and the region of the porta hepatis edematous. Three subcostal Surgiports were then introduced at this time under direct visualization, medially a 10-mm port, laterally a pair of 5-mm ports through which graspers were passed to grasp the fundus and eventually the neck of the gallbladder.

Using sharp and blunt dissection, the region of the porta hepatis was dissected to a point where the cystic duct was eventually identified coming off the gallbladder, going into a fairly edematous porta hepatis. The gallbladder was further dissected from its intrahepatic bed until positive identification of the cystic duct could be identified. This was followed down to where it joined with the common bile duct and then, at its highest point, the cystic duct was doubly clipped and transected. The gallbladder was sharply dissected from the edematous intrahepatic bed using hook cautery and Endoshears. In the process, the cystic artery was isolated, doubly clipped and transected, and then the gallbladder removed.

Prior to detachment, hemostasis was verified as being secure. Once detached, the gallbladder was brought out through the umbilical opening by bringing the laparoscope to the upper medial port. Under direct visualization, the gallbladder was grasped and taken out through the umbilical wound, which had to be widened to accommodate its size.

Once this was done, the abdomen was desufflated. The umbilical wound was closed with figure-of-eight 1-0 Maxon sutures on the fascia and 4-0 Monocryl on the skin. The subcostal ports were closed with 4-0 Monocryl. Marcaine 0.25% was infiltrated for postoperative analgesia.

PROCEDURE: Open Herniorrhaphy With Mesh

With the patient in the supine position under spinal anesthesia, the lower part of the patient's abdomen was properly prepped and draped.

An oblique incision, parallel to the right Poupart ligament was first made. Incision was carried down through the subcutaneous tissues and the Scarpa fascia to the aponeurosis of the external oblique. A huge sac was found, dissected free from the surrounding tissues. The contents of this sac, which was not only a direct sac, but in continuity extending to the transversalis fascia, was dissected free from the surrounding tissues. The sac was opened, and the lipoma and the sac were ligated with 2-0 Prolene and amputated. There was a clear-cut ischemic area in the ring of the sac, indicating a partial incarceration.

The repair of the hernia was then started by reapproximating the conjoined tendon to the Poupart ligament with 2-0 Prolene and clips. Because the conjoined tendon was quite muscular, the decision was made to use mesh. The mesh was sutured with interrupted sutures medially to the conjoined tendon and laterally to the Poupart ligament; some clips were also used. The cord structures were coming out laterally.

The aponeurosis of the external oblique was then reapproximated above the mesh to prevent any indirect contact of the mesh with the cord structures. The entire area was infiltrated with Marcaine. The cord structures were left in the subcutaneous tissues. The subcutaneous tissues were reapproximated above the cord with 3-0 Maxon. The skin was closed with clips.

OPERATIVE PROCEDURE: Laparoscopic Herniorrhaphy/Umbilical Herniorrhaphy

The patient was brought to the operating room. Venodyne boots were then placed. Once under adequate general anesthesia, the patient was prepped and draped in the usual sterile fashion.

A curvilinear incision was made infraumbilically through the skin and underlying subcutaneous tissue, taking care not to injure the umbilical hernia sac. The fascia on the right side was then visualized and cleared off of all overlying tissue. A nick was made in the fascia, revealing underlying musculus rectus abdominis. This nick was increased in size to fit the 10-mm trocar. The rectus muscle was then retracted laterally revealing the underlying posterior rectus sheath.

A peanut was then placed to create the preperitoneal space, followed by the Origin balloon. The balloon was then advanced to the pubic tubercle with no resistance. Under visualization, the balloon was inflated in the preperitoneal space. The balloon was allowed to remain in the preperitoneal space for a few minutes to tamponade any bleeding. During this tamponading process, the area was inspected. On the right, the epigastrics were noted to be down. Cooper ligament was exposed, as was on the left. Inspection of the left side, however, revealed the possibility of a left hernia, a hint of which was found on preoperative examination.

The balloon was then removed. Through the same incision, an Origin 10-mm trocar was placed. A pneumopreperitoneum was established.

Laparoscopic exploration of the preperitoneal space revealed that the epigastrics were indeed down on the right side. They were then divided between ligatures, placed proximally and distally, and tied extracorporeally. These ligatures were of 1-0 silk.

With the epigastrics divided, attention was placed toward dissection in the right pelvis. Dissection revealed a cord lipoma on the right, which was reduced, and a small hernia sac which was also easily reduced. Lateral dissection was accomplished to a point where the iliopectineal line could be identified. Medially, Cooper ligament was identified.

The entire cord was then lifted and a large window underneath the cord was made to place the mesh. The mesh was then fashioned and keyholed with a lateral oblique keyhole incision. It was then placed into the preperitoneal space and positioned around the cord, such that the cord sat in the keyhole. Once properly positioned with the mesh covering the indirect, direct and femoral spaces, it was tacked in place using the Origin tacker, placing tacks on Cooper ligament, on the anterior abdominal wall, and in such a way to reconstruct the internal ring and also close the keyhole. With this complete, the mesh was inspected and it was noted to cover the indirect, direct and femoral spaces well, and the area was noted to be hemostatic.

Attention was then placed toward the left. Dissection of the cord proceeded with the finding of a rather large cord lipoma, which was easily reduced. There was no hernia sac found in the space; however, inspection of the internal ring with the cord lipoma reduced, revealed a quite large internal ring. Therefore, it was decided to place a mesh, which was then constructed and placed in a similar fashion as described for the right side.

The entire area was then irrigated, inspected and noted to be hemostatic. The pneumopreperitoneum was then reduced under direct visualization to visualize the mesh staying in place and no peritoneum sneaking underneath the mesh.

The 5-mm trocar sites were then closed in a subcuticular fashion. The fascial defect in the right rectus abdominis sheath was then closed with a simple figure-of-eight 1-0 Vicryl suture.

Next attention was placed toward the umbilical hernia. The fascia around the hernia defect was identified and cleared of surrounding tissue, approximately 1.5-cm around the umbilical hernia, which was large enough to accept the tip of a finger. The sac was then reduced back into the abdomen, revealing the entire rim of the umbilical hernia. Next a plug and patch was then fashioned and placed in the umbilical hernia. It was sewn in place at its superior and inferior aspects with 1-0 Vicryl, taking part of the patch mesh and tacking it to the underlying fascia. Then in a circular fashion, tacks from the 5-mm tacker were then placed to further hold the mesh down to the fascia.

The area was then irrigated out copiously and inspected. The mesh was noted to be in good position and tacked down well. The underside of the umbilicus was then tacked down to the mesh to recreate an inward contour. The curvilinear incision was then closed using interrupted 4-0 subcuticular sutures.

The patient tolerated the entire procedure well. Steri-Strips and sterile bandages were placed. All instrument and sponge counts were reported correct at the end of the procedure. The patient was sent to the recovery room in stable condition.

OPERATIVE PROCEDURE: Laparoscopic Toupet antireflux surgery

PREOPERATIVE DIAGNOSIS: Medically refractory gastroesophageal reflux disease with hiatal hernia.

POSTOPERATIVE DIAGNOSIS: Medically refractory gastroesophageal reflux disease with hiatal hernia.

DESCRIPTION OF PROCEDURE: After induction of general anesthesia via endotracheal intubation, the patient was prepped and draped in sterile fashion. An NG tube was placed by Anesthesia. Two 5 and 12 dilating trocars and four 5-mm trocars were placed in the upper abdomen in standard fashion for a laparoscopic Toupet. The left lobe of the liver was lifted out of the way and a grasper was placed on the diaphragm above the esophageal hiatus to hold it out of harm's way. The gastrohepatic ligament was cut using cautery and a large vessel was encountered. The area was first cauterized using bipolar before cutting it. The right crus was identified and dissected down to its confluence with the left crus and then a posterior window behind the esophagus was created. The esophageal retractor was placed to widen this.

The grasper was then placed behind the esophagus and a super blue maxi loop was passed around the esophagus and its ends ligated with Endoloop. This was used for retraction. Peritoneal attachments anteriorly over the right crus to the left crus were taken down, thus allowing about a 3-4 cm segment of esophagus to fall intra-abdominally. The posterior window was again widened, a grasper was placed behind the esophagus and the fundus of the stomach pulled as a wrap to the other side. This was stapled to the left crus using the Ethicon hernia staple device. A suture of 0 Ethibond was placed from the esophagus to wrap to right crus in the 9 o'clock position, ends ligated x4, cut and doubly clipped to mark it radiographically.

The NG tube was removed and 30 French bougie dilator was placed. The wrap was then attached to the right crus using Ethicon hernia staple device. It was also attached to the right anterolateral aspect of the esophagus using 3 Ethicon hernia staples. A 2nd stitch of 0 Ethibond was placed from the fundus of stomach to the left crus and esophagus in the 3 o'clock position, ends ligated x4, cut and doubly clipped to mark it radiographically. Fundus was then attached to the left anterolateral aspect of the esophagus again using the Ethicon hernia staple device, using 3 staples. Once this was accomplished, he had a good partial wrap of about 270 degrees.

The super blue maxi loop was cut and removed from the abdomen. The grasper was taken off the diaphragm and removed under direct visualization. No bleeding was noted. Carbon dioxide was allowed to leave the abdomen and all trocars were removed. Incisions were closed using dermal stitches of 4-0 Vicryl. Benzoin, Steri-Strips, and dressings with Cover-Roll were applied. The patient was then extubated. The bougie dilator was removed and patient was brought to the recovery area in good condition.

End of Procedure

Many thanks to Sara Johnson for submitting this report.