Thank you very much.
Posted By: NewbieMT on 2006-01-20
In Reply to:
Subject: Thank you very much.
I am really impressed by the expertise I received from CL and Jan. After listening to the dictation a second time after your feedback everything became so much clearer to me.
You have no idea of how much I appreciate the help from the both of you. Here is the completed report. There are 3 blanks that I just could not get. I have learned a lot from this op note which is my first on the job. It was very difficult. But I try to produce quality work all of the time.
Here is the finished report:
PREOPERATIVE DIAGNOSIS: Paraesophageal hernia and gastric volvulus.
POSTOPERATIVE DIAGNOSIS: Paraesophageal hernia and gastric volvulus with colon in chest.
PROCEDURE: Laparoscopic repair of paraesophageal hernia.
ANESTHESIA: General endotracheal.
ESTMATED BLOOD LOSS: 10 mL.
SPECIMEN: Hiatal hernia sac.
COMPLICATIONS: None.
PROCEDURE: Patient was placed in the supine position on the operating table, and after induction of general anesthesia the patient's abdomen was prepped and draped. A 12-mm midline incision was made at the umbilicus, and a Veress needle was used to create a pneumoperitoneum to 15 mmHg pressure. A 12-mm Visiport trocar and 0-degree laparoscope were placed in the peritoneal cavity under laparoscopic visualization. The patient was then placed into reverse-Trendelenburg position and additional ports were placed. A right subcostal 5-mm trocar was placed for placement of a flexible liver retractor and this is used to elevate the ___ over the liver away from the anterior wall of the stomach. A 5-mm right paraxiphoid trocar was placed and a 12-mm left paraxiphoid trocar was placed, and then an additional 5-mm trocar at the level of the umbilicus on the left side of the abdomen. Upon inspection of the abdominal cavity, it was noted that the patient had a large hiatal hernia that included contents of the short ___ of the stomach, which also was complete gastric volvulus and also the omentum and a portion of the transverse colon. These were easily reduced into the abdominal cavity just leaving a portion of the superior aspect of the stomach within the chest. At this point, using the harmonic scalpel along the anterior edge of the hiatal hernia defect, the sac was sharply and bluntly dissected out from the chest and reduced into the abdomen. After completely reducing the hiatal hernia sac into the abdominal cavity, short gastrics were then divided along the greater curvature of the stomach and to identify the left crus of the diaphragm. At this point, interest was then turned to the right crus of the diaphragm and a small gastric vessel was then clipped and divided. At this point, access was gained posterior to the esophagus above the GE junction and the Penrose drain was passed behind this and grasped with an instrument to the trocar in the left lower quadrant. At this point, using the harmonic scalpel, the hernia sac was amputated away from the stomach and esophagus to remove through a 12-mm port site. Upon inspection of the stomach and esophagus, there was noted to be approximately a 1-cm defect in the anterior wall of the GE junction, and at this point, this was oversewn with a running 2-0 Vicryl suture. An orogastric tube was placed by anesthesia and methylene blue dye was instilled and noticed this small leak from the superior aspect of the suture line. At this point, the suture line was then imbricated with interrupted figure-of-8 sutures for reinforcement and a methylene blue test was again done and revealed no leak from the repaired defect. At this point, the fundus of the stomach was completely freed up and brought posterior to the GE junction for completion of the Nissen fundoplication. With the orogastric tube still in place, a fundic wrap was created using 3 interrupted sutures of 2-0 Ethibond suture at the GE junction at the level of the previously repaired perforation. This segment of wrap measured approximately 1.5 cm in length. At the completion of this, the orogastric tube was removed and the defect in the hiatus was closed with 4 interrupted sutures of 2-0 Ethibond. These were closed posteriorly to approximate the right and left crus and 2 stitches were used anteriorly to completely close the defect around the esophagus. In fact, at the completion of this, the abdominal cavity was inspected, and the liver retractor was removed. Trocar was further removed and the abdominal cavity was desufflated and the umbilical port site was closed to the level of the fascia with a 0-Vicryl suture. The skin is then ___ approximated with 4-0 Vicryl and then Steri-Strips and Band-Aids were applied. The patient was extubated in the operating room and transferred to recovery room.
PLAN: Admission to the intensive care unit overnight. During the procedure, the patient's AICD was turned off with use of a magnet and turned on at the end of procedure by removal of the magnet.
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