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manage airway secretions, airway obstruction at or above the level of the larynx, ]
Postoperative Diagnosis:Same
Procedure(s)Performed :Tracheostomy, Flexible Bronchoscopy(DETAILS – e.g. type and size of tracheostomy placed)
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]year old[GENDER]with[DURATION]history of [COMPLAINT– e.g. respiratory
failure, need for prolonged airway management, inability to manage airway secretions, airway obstruction at or above the level
of the larynx].
Description of Procedure:The patient was identified in the pre-operative holding area and taken to the operating
room on [DATE]. The patient’s identity and planned procedure verified, and the patient was placed on the operating
room table in the supine position. General anesthesia was obtained. A shoulder role was placed to assist in neck
hyperextension. The neck and anterior chest were then prepped and draped in sterile fashion. A time out was
performed prior to beginning the procedure. The patient was pre-oxiginated with 100% FiO2. The trachea, cricoid
cartilage, thyroid cartilage and sternal notch were palpated. A 4 cm midline transverse incision was made one
fingerbreadth above the suprasternal notch. The incision was carried down through the subcutaneous tissues using
cautery. The platysma was divided with cautery. The strap muscles were identified, divided in the midline, and
retracted laterally. The thyroid gland was retracted superiorly, and dissection continued down to the level of the
pretracheal fascia. Hemostasis was maintained. The second tracheal ring was identified. A tracheostomy hook was
placed between the first and second tracheal rings and the tracheal was retracted superiorly. The FiO2 was
decreased to room air. Anesthesia was instructed to deflate the endotracheal tube balloon prior to incising the
trachea. Using an #11 blade scalpel, a vertical incision was made in the trachea between the 2nd and 3
rd
tracheal
rings. The endotracheal tube was withdrawn so that its tip was immediately proximal to the tracheostomy site. A #
8 tracheostomy tube was successfully inserted and advanced into the trachea. The tracheostomy balloon was inflated
and the tracheostomy was connected to the ventilatory circuit. Placement was confirmed by return of end tidal C02.
Oxygen saturations were excellent. A flexible bronchoscope was placed through the tracheostomy tube to confirm
appropriate placement under direct vision. The tracheostomy tube was secured in place using a #2-0 Prolene sutures
in each of the four quadrants. A soft tracheostomy tie was placed around the patient’s neck leaving two
fingerbreadths space beneath the tape. Bronchoscopy was performed through the endotracheal and tracheostomy
tubes to ensure hemostasis and for pulmonary toilet. There were no immediate complications. Counts were correct x
2 at the end of the case. The patient tolerated the procedure well. A post-operative chest xray was ordered. The
attending surgeon was scrubbed and present for the critical portion of the procedure. The patient was subsequently
transferred to intensive care unit in stable condition.
Dr.[BLANK]was present and scrubbed for[BLANK]elements of this procedure.
19. Tracheal Resection and Reconstruction
Cameron T. Stock, MD and Douglas J. Mathisen, MD
Massachusetts General Hospital, Boston, MA
Essential Operative Steps
1. Careful radiologic evaluation
2. General endotracheal anesthesia
3. Preoperative bronchoscopic evaluation of the trachea by the operating surgeon
4. Dilation of the stenotic tracheal segment to secure the airway for resection or palliation until resection can be
safely performed
5. Careful dissection of the trachea from surrounding structures staying immediately on the tracheal surface to avoid
injury to the recurrent laryngeal nerve
6. Cross field ventilation
7. Placement of traction sutures in the midlateral position on the proximal and distal tracheal ends to gauge tension
on the anastomosis and to take tension off the anastomosis when tying the anastomotic sutures.
8. Placement of interrupted absorbable sutures in an organized and systematic fashion for the anastomosis
9. Coverage of the anastomosis with a pedicled muscle flap
10. Neck drainage / placement of a guardian stitch
Potential Complications and Pitfalls
1. Poor preoperative patient selection
2. Injury to the recurrent laryngeal nerve by electrocautery or sharp dissection
3. Excessive tension on the anastomosis when tying
4. Compromise of the tracheal blood supply by excessive dissection
5. Injury to the brachiocephalic artery during dissection inferiorly
6. Postoperative wound infection
7. Air leak/subcutaneous air
8. Anastomotic separation/dehiscence
Template Dictation
Preoperative Diagnosis: Tracheal stenosis, tracheal malignancy
Postoperative Diagnosis: Same
Procedure(s) Performed: Tracheal resection and reconstruction, muscle flap coverage of the anastomosis
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [INDICATIONS, e.g., post-intubation tracheal stenosis,
tracheal mass, etc.] who presented with increasing dyspnea and audible stridor with exertion. Preoperative imaging showed
[CXR and CT findings] and bronchoscopy revealed [BRONCHO SCO PIC FINDINGS AND PATHOLOGY RESULTS].
After discussing the risks and benefits of the procedure, the patient provided informed consent for a flexible bronchoscopy,
tracheal resection and reconstruction and muscle flap coverage of the anastomosis.
Description of Procedure: The patient was brought to the operating room on [DATE]. The patient was confirmed with two
unique identifiers and the correct procedure was verified. The patient was placed supine on the operating table and general
anesthesia was administered. After flexible bronchoscopy revealed healed, non-inflamed tracheal mucosa at the area of known
stenosis, the patient’s neck was extended by insufflating the thyroid bag placed under the patient’s shoulders, and the head was
supported with blankets. The patient’s neck and chest were prepped and draped in the usual fashion. A time out was
performed. A low transverse collar incision was made between the cricoid cartilage and the sternal notch. The incision was
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carried through the dermis and subcutaneous fat to the platysma. The platysma was divided transversely and cutaneous sub-
platysmal flaps were raised to the level of the cricoid superiorly and the sternal notch inferiorly. Gelpi retractors were placed
at the lateral aspects of the incision for exposure. The midline of the trachea was identified and the overlying sternohyoid and
sternothyroid muscles were dissected off the surface of the trachea laterally for a short distance. The cricoid cartilage was
identified in the midline and the anterior surface of the trachea was dissected to the thyroid isthmus. The isthmus was divided
sharply and the ends were suture ligated. At the level of the sternal notch dissection of the pretracheal fascia was initiated
using finger dissection and the anterior surface of the trachea was dissected bluntly down to the carina. This maneuver was
employed to allow the distal trachea to slide cephalad with less tension when creating the anastomosis.
Sharp dissection of the affected tracheal segment was performed using scissors and short bursts of electrocautery. Care was
taken to stay immediately on the surface of the trachea to avoid injury to the recurrent laryngeal nerve. Circumferential
dissection of the trachea was completed only on the affected segment. The trachea was divided between cartilages distal to the
tracheal lesion and the trachea was retracted cephalad to facilitate posterior dissection. Care was taken to avoid injury to the
esophagus. Ventilation of the distal trachea was performed by intermittent cross field ventilation with sterile tubing and an
armored Tovell endotracheal tube. After careful dissection of the tracheal lesion was completed, it was divided sharply on the
proximal end of the affected segment and the specimen was passed off the field.
The tracheal ends were inspected and determined to be satisfactory to complete the anastomosis. Full thickness #2-0 Vicryl
traction sutures were placed around the cartilage 1.5 cm from the cut tracheal ends on the proximal and distal airway in the
midlateral position on both sides of the trachea. Next, the neck was flexed by deflating the thyroid bag and placing 2-3 folded
blankets under the patient’s head. The proximal and distal traction sutures were grasped on either side of the trachea and by
pulling them together it was determined there would not be excessive tension on the completed anastomosis. The anastomosis
was performed using interworked #4-0 Vicryl stitches. The first stitch was placed in the posterior membranous trachea at the 6
o’clock position such that the knot would was on the outside of the trachea. The ends were clipped to the drapes cephalad at
the 12 o’clock position. Subsequent stitches were placed on the posterior wall of the tracheal to level of the lateral traction
sutures and were clipped to the drapes in the caudal position. Each subsequent suture was affixed anterior to the proceeding
stitch on the drapes. Sutures were placed approximately 4 mm apart and 2-3 mm from the cut end of the trachea such that all
knots would lie on the outside. Cross field ventilation was performed between stitches. Next, stitches were placed from
traction suture to traction suture along the anterior wall of the trachea and the ends were clipped to a surgical towel placed
cephalad to the incision. After all the anastomotic stitches were placed the proximal and distal traction sutures were then tied
to each other, pulling the tracheal ends together. Next the #4-0 Vicryl stitches placed along the anterior wall were tied from
traction suture to traction suture. The stitches on the back wall were then tied, first on the left side followed by the right side.
The anastomosis was inspected and found to be satisfactory by deflating the cuff on the endotracheal tube, closing the nose and
mouth, and giving a breath to 20-40 cm of H
2
0 pressure.
Next the right sternothyroid muscle was identified and dissected from the sternohyoid muscle. It was divided inferiorly and
rotated over the anastomosis and sutured in place over the anastomotic suture line using interrupted #4-0 Vicryl sutures in a
mattress fashion. The sternohyoid muscles were closed in the midline using interrupted sutures. A #10 flat Jackson-Pratt drain
was placed in the neck near the anastomosis and the platysma and skin were closed. All instrument, sponge and needle counts
were confirmed to be correct. A heavy #2 Vicryl “guardian” stitch was placed from the chin to the presternal skin to prevent
tension on the anastomosis. A sterile dressing was applied to the neck incision. The patient was extubated and brought to the
ICU in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
20. Esophageal Stent Placement
Thomas Caranasos, MD and Kfir Ben-David, MD
University of Florida, Gainesville, FL
Essential Operative Steps
1. Preoperative imaging to determine pathology (Malignant esophageal stricture, Begin esophageal stricture, Esophageal
perforation, Leak following esophageal or gastric surgery, Tracheoesophageal fistula)
2. Appropriate noninvasive monitoring
3. Conscious sedation or general endotracheal anesthesia.
4. Introduction of the scope into the esophagus to the pylorus or duodenum depending on pathology
5. Examination of the stomach and hiatus with retroflexion
6. Examination of the GE junction and esophagus
7. Recognition of pathology
8. Deployment of the stent
9. Examination of appropriate positioning
10. Safe withdrawal of the scope
Potential Complications and Pitfalls
1. Appropriate administration of sedation (avoiding over-sedation, hemodynamic instability, or aspiration)
2. Introduction of the scope within the esophagus
3. Careful advancement of the scope, especially in the face of stricture as to not cause perforation.
4. Appropriate examination of the entire stomach, possibly the duodenum, GE junction, and esophagus for underlying
pathology. Biopsy if needed.
5. Management of bleeding with clips or submucosal epinephrine injection
6. Deployment of stent bridging area of pathology
7. Anchoring the stent to prevent stent migration
8. Evaluation of placement of the stent for concern of perforation or mucosal injury
9. Appropriate timing of stent removal to avoid late complications (Perforation, Erosion, Migration, Bleeding)
Template Dictation
Preoperative Diagnosis: Esophageal Perforation
Postoperative Diagnosis: Same
Procedure(s) Performed: EGD, Esophageal Stent Placement
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [Blank] is a 60 year old male who is post procedure day 2 from EGD for Achalasia. He returned
to the hospital with worsening mid-epigastric pain. Oral contrasted CT imaging showed evidence of distal esophageal leak.
The risks, benefits, and alternatives to the above procedure were discussed at length with the patient and he agreed to and
accepted the risks.
Description of Procedure: The patient was brought to the endoscopy suit. Noninvasive blood pressure and continuous heart
rate and pulse oximetry monitoring were utilized throughout the procedure. Versed and fentanyl were used for conscious
sedation. The endoscope was introduced through the bite block in the mouth and into the posterior oropharynx. The vocal
cords were visualized anteriorly and the scoped passed posterior to the left arytenoid and into the esophagus. Under direct
visualization the scope was carefully advanced. The proximal and middle esophagus appeared normal. A [Finding and
description - e.g. 10 mm mucosal laceration was noted at 38 cm from the incisors. The tear was located on the left anterior-
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lateral portion of the esophagus. The lesion extended from 38-39 cm from the incisors]. The GE junction was measured at [X]
cm from the incisors. The scope is slowly advanced into the stomach and retroflexed to examine the GE junction. No evidence
of hiatal hernia or gastric perforation was visualized. The stomach and first portion of the duodenum were examined. No
abnormalities were noted. The scope was slowly withdrawn 10 cm proximal to the level of the [lesion to be stented]. Under
direct endoscopic visualization, a 0.97 mm guide wire was advanced into the stomach. A [dimensions X by X] [brand] stent
was deployed according to the manufacturer’s recommendation. The proximal end of the stent was positioned at [X] cm from
the incisors with the distal end bridging the GE junction and positioned in the stomach. The string at the proximal end of the
stent was clipped to the mucosa with two endo-clips to prevent migration. The scope was then passed back into the stomach to
confirm appropriate positioning and slowly withdrawn and removed. The bite block was removed and the patient transferred
to the endoscopy recovery room in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
21. Laparoscopic Nissen Fundoplication
Luis F. Alberton, MD and Sean Kwon, MD
North Shore Long Island Jewish Health System, New Hyde Park, NY
Essential Operative Steps
1. Lithotomy position or supine with foot rest to allow steep reverse Trendelenburg position
2. Foley catheter
3. Additional peripheral IVs +/- arterial line
4. Gain access to abdominal cavity with Veress needle or open Hassan technique
5. Inspect abdominal cavity and place additional ports
6. Place liver retractor to provide exposure of hiatus
7. Mobilize lesser curvature, divide gastrohepatic ligament
8. Dissect right crus
9. Mobilize greater curvature
10. Dissect left crus
11. Complete anterior portion of mediastinal dissection of the distal esophagus starting on the pericardium anteriorly and
then working from pleura to pleura
12. Take down retrogastric and retroesophageal attachments and identify the decussation of the right and left crus
13. Complete the mediastinal dissection in the posterior (periaortic plane) until the distal esophagus has been mobilized
circumferentially taking care to spare both vagal trunks
14. Dissect the GEJ fat pad to identify the true GEJ
15. Collis gastroplasty if there is inadequate length of intraabdominal esophagus
16. Place Bougie (i.e., 54 Fr)
17. Grasp fundus along the line of the short gastrics and pass from left to right in the retroesophageal window inside of
the vagus nerves
18. Shoe shine technique to assure the absence of rotational torsion
19. Place 2 to 3 sutures to secure the wrap around the esophagus
20. Remove Bougie
21. Close diaphragmatic hiatus
22. Remove liver retractor and ports under direct visualization
23. Close port sites
Special Equipment
1. 5 and/or 10 mm 30 or 45 degree laparoscopes
2. Endoscopic suturing instrument or pledged sutures
3. Self-retaining liver retractor
4. Electrocautery / ultrasonic dissector
Potential Complications and Pitfalls
1. Injury to abdominal viscera or blood vessels while entering the abdominal cavity.
2. Esophageal or gastric perforation
3. Tension pneumothorax
4. Hypotension secondary to CO2 insufflation
5. Injury to replaced left hepatic artery while dissecting gastrohepatic ligament
6. Spleen or splenic vascular injury
7. Bleeding secondary to injury to the short gastrics
8. Wrap or hiatal closure too tight or too loose
9. Injury to vagus nerves
10. When dissecting the GEJ fat pad, always work from right to left
11. Inadequate mobilization of the esophagus and failure to recognized a short esophagus
12. Constructing the wrap around the cardia
13. Denuding the peritoneum off the right or left crus
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Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. reflux disease unresponsive to medical therapy]
Postoperative Diagnosis: Same
Procedure(s) Performed: Laparoscopic Nissen Fundoplication and hiatal hernia repair
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesiologist: [BLANK]
Anesthesia: GETA IVF: [BLANK] EBL: [BLANK] UO: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATIO N] history of gastroesophageal reflux disease
manifesting as [SYMPTOMS] that has failed to respond to maximal medical therapy. [HIS/HER] preoperative evaluation has
included a barium esophagram which revealed [FINDING S]. Esophageal manometry demonstrated [FINDING S]. A pH
study demonstrated a DeMeester score of [X]. A upper endoscopy was obtained which revealed a [X] cm hiatal hernia and
[OTHER FINDINGS, i.e., Barrett’s esophagus, esophagitis, etc]. After discussing the risks and benefits of the procedure,
the patient provided informed consent for a laparoscopic Nissen fundoplication and hiatal hernia repair.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were verified, and the patient was placed on the operating room table in the supine position. Sequential
compression devices were placed in both legs for DVT prophylaxis. Following an uneventful induction of general anesthesia,
the patient was intubated without incident. A Foley catheter was inserted. [Patient was placed on lithotomy position]. The
abdomen was then prepped and draped in the usual sterile fashion. The camera and insufflation equipment were connected and
checked. A time out was then performed according to hospital policy.
Access to the abdominal cavity was obtained using [Hassan/Veress needle] technique. A camera port was placed in the
midline supraumbilical area, approximately 15cm from the xiphoid process. Pneumoperitoneum was established with carbon
dioxide to a pressure of 15 mmHg, paying close attention to the vital signs and flow and total volume of gas infused.
Inspection of abdominal cavity was performed and no abnormalities or injuries were identified. Four additional ports were
placed. A 10-mm trocar was placed below the left costal margin, 11 cm away from the xiphoid process. A 5-mm assistant's
port was placed a hand’s breadth lateral to the 10 mm trocar along the left costal margin. A 5-mm trocar for the liver retractor
was inserted just below the right costal margin in the lateral aspect of the right upper quadrant. A self-retaining liver retractor
was then used to elevate the left lateral segment of the liver to expose the esophageal hiatus. The retractor is stabilized with a
table-mounted mechanical arm. An additional 5-mm trocar was inserted just to the right side of the Falciform ligament and
angled toward the hiatus.
Once all the trocars were in place, the gastrohepatic ligament was divided directly over the caudate lobe using
[electrocautery / ultrasonic dissector]. The dissection was continued towards the base of the right crus. The medial border
of the right crus was defined, taking care to preserve its peritoneal lining. We began the lateral mediastinal portion of the
dissection, sweeping the pleura laterally. We then divided the peritoneum anteriorly and continued along the medial border of
the left crus, taking care to preserve its peritoneal lining. We then completed mobilization of the distal esophagus in the
anterior plane, working directly on the pericardium and then working from pleura to pleura, taking care to preserve the anterior
vagus nerve.
Attention was then directed to the greater curvature of the stomach. The gastrosplenic ligament was opened with the ultrasonic
dissector, and the short gastric vessels were divided to the level of the Angle of His. We then completed our dissection along
the medial border of the left crus.
Attention was then redirected to the lesser curvature of the stomach. The stomach was elevated. The retroesophageal and
retrogastric attachments were taken down. [A Penrose drain was passed around the esophagus and used for retraction.]
The distal esophagus was then mobilized posteriorly in the pre-aortic areolar soft tissue plane. The distal esophagus was then
circumferentially mobilized. Both vagal trunks were identified and were spared during the dissection. In order to identify the
true gastroesophageal junction, we mobilized the GEJ fat pad laterally off the esophagus, sparing both vagal trunks. We noted
approximately [x] cm of intraabdominal esophagus. [Variation: Collis gastroplasty may be performed if a short esophagus
(<2 cm of intra-abdominal length) is present]. The Penrose drain was removed.
The posterior aspect of esophageal hiatus was then closed with interrupted [SIZE and TYPE; e.g, non-absorbable, pledged]
sutures. The fundus of the stomach was then grasped and passed from left to right in the retroesophageal window between the
esophagus and the fat pad. The lines of the short gastrics on either side of the wrap were aligned with one another, thereby
forming a 360 degree wrap. A [SIZE] Bougie was advanced transorally down the esophagus and into the stomach under
direct vision. We performed a “shoeshine maneuver” to assured the absence of rotational torsion. The wrap was then sutured
in place using [TYPE AND NUMBER OF SUTURES], taking a bite of the fundus on one side, the esophagus, and then the
fundus on the other side. The Bougie was removed. An NG tube was placed under and the liver retractor and ports then
removed under direct visualization. The abdominal cavity was again inspected and no bleeding or sites of injury were seen.
Pneumoperitoneum was then desufflated. The fascial incisions of the 10 mm ports were closed with [SUTURE]. Finally the
skin was closed with [SUTURE / GLUE] and sterile dressings then applied.
All instrument, sponge and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
subsequently transferred to the postanesthesia care unit in satisfactory condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
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22. Laparoscopic Paraesophageal Hernia Repair
Andrew B. Nguyen, MD and James D. Luketich, MD
University of Pittsburgh Medical Center, Pittsburgh, PA
Essential Operative Steps
1. Upper endoscopy.
2. Supine position (far right on operating bed), arms out 45 degrees, and foot board placement for steep reverse
Trendelenburg.
3. Place 10 mm port via open Hasson technique in the right paramedian line approximately one-third of the way from the
xiphoid to the umbilicus.
4. CO
2
insufflation to 15 mmHg.
5. Confirm position within the peritoneal cavity and inspect abdomen with laparoscope.
6. Place additional ports under direct laparoscopic visualization. An 11 mm left paramedian port one hand’s breadth to
the left initial cutdown port. A 5 mm right and left subcostal port a hand’s breadth from the paramedian port sites. A
5 mm port in the lateral right upper quadrant directed along the lower edge of the liver.
7. Insert liver retractor to elevate the left lobe of the liver for exposure of the hiatus.
8. Place patient in steep reverse Trendelenburg position to facilitate visualization of the hiatus.
9. Reduce herniated content gently while avoiding placing traction on the stomach.
10. Evert and incise hernia sac anteriorly.
11. Complete the anterior portion of the dissection, beginning on the pericardium and then working from pleura to pleura.
12. Open the gastrohepatic omentum directly above the caudate lobe
13. Define the medial border of the right crus, while preserving its peritoneal lining.
14. Divide the short gastric vessels.
15. Define the medial border of the left crus, while preserving its peritoneal lining.
16. Medistinal dissection in areolar periaortic soft tissue plane
17. After mobilizing the esophagus circumferentially to the level of the inferior pulmonary veins, excise the hernia sac
18. For a Nissen-Fundoplication
1. Dissect gastric fat pad off stomach to precisely identify the gastroesophageal junction.
2. Develop a retroesophageal window between the esophagus and posterior vagus nerve.
3. Pass a 54-French bougie transorally into the stomach under direct laparoscopic visualization.
4. [Perform Collis gastroplasty if more intrabdominal esophageal length is required.]
5. Create a “floppy” Nissen wrap.
19. For a gastropexy:
1. Interrupted u-stitches between the line of the short gastrics and left hemidiaphragm
20. Close hiatus with interrupted sutures approximating crura posteriorly (and anteriorly if necessary).
21. Place NG tube
22. Close
Potential Complications and Pitfalls
1. Avoid upper overinsufflation during upper endoscopy which will increase the difficulty of a laparoscopic repair.
2. Trocar injuries.
3. Injury to esophagus.
4. Injury to stomach.
5. Injury to spleen.
6. Vagal nerve injury. Be cognizant of the location of both nerves during the dissection. Minimize the risk of anterior
vagal nerve injury by beginning the dissection anteriorly and dissecting in the areolar soft tissue plane. Dissect the fat
pad by working from left to right
7. Inadequate esophageal mobilization or failure to recognize a short esophagus can result in a recurrence. Many
patients with giant paraesophageal hernias require gastroplasties
8. A poorly planned gastroplasty can result in undue angulation of the stomach
9. An excessively tight hiatal repair can cause obstructive symptoms. An excessively loose repair can contribute to a
recurrence.
10. Hypercapnea from CO2 insufflation
11. Pneumothorax
Template Dictation
Preoperative Diagnosis: Paraesophageal hernia
Postoperative Diagnosis: Same
Procedure(s) Performed: Laparoscopic paraesophageal hernia repair
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: This is a [AGE]-year-old male/female who presented with [SYMPTOMS AND SIGNS]. The
patient was found on [ESO PHAGRAM/UPPER ENDO SCOPY/COMPUTED TOMOGRAPHY SCAN] to have a type
[II/III/IV] paraesophageal hernia involving a large portion of the stomach/ +/- OTHER ABDOMINAL STRUCTURES].
The risks and benefits had been discussed with the patient regarding surgical repair. The patient provided informed consent
for an upper endoscopy, laparoscopic (possible open) paraesophageal hernia repair, and [NISSEN
FUNDOPLICATION/GASTROPEXY], [AND POSSIBLE COLLIS GASTROPLASTY].
Description of procedure: The patient was identified in the preoperative area, taken to the operating room, and placed supine
on the operating table. General anesthesia was induced. The patient was intubated with a single-lumen endotracheal tube.
[CEFAZOLIN/OTHER ANTIBIOTIC] was given for perioperative antibiotic prophylaxis. A Foley catheter was inserted.
Sequential compression devices were placed bilaterally in the lower extremities and a dose of 5000 units of subcutaneous
heparin was given for deep venous thrombosis prophylaxis. A proper time-out was conducted.
An upper endoscopy was first performed. A flexible endoscope was inserted transorally and advanced distally into the
esophagus. The esophagus appeared [DESCRIBE FEATURES, NORMAL, ESOPHAGITIS, BARRETT’S ESOPHAGUS,
ETC]. The gastroesophageal junction was noted at about [LOCATION FROM INCISORS] cm and the crural pinch at
[LOCATION FROM INCISORS] cm from the incisors, consistent with a [SIZE] hiatal hernia. The endoscope was advanced
into the stomach, which had herniated in the chest. Care was taken to not over insufflate the stomach to avoid gastric and
intestinal distention. The scope was advanced through a patent pylorus into the duodenum, which appeared normal. The
duodenum, stomach, and esophagus were then desufflated as the endoscope was withdrawn.
The patient is positioned far right on the operating room table in preparation for the subhepatic liver retractor. A foot board
was placed for support during steep reverse Trendelenburg positioning. The patient’s arms were secured to the arm board,
carefully padded, and rotated 45 degrees away from the bed. The patient was then prepped and draped in the usual sterile
fashion.
The first port was placed using the open Hasson technique in the right paramedian line approximately one-third of the distance
from the xiphoid process to the umbilicus. The skin was incised and the subcutaneous tissue was bluntly dissected with S
retractors. The anterior sheath was opened vertically with electrocautery. The S retractors were used to separate the rectus
muscles in the direction of the fibers. The posterior sheath was then grasped with tonsils, elevated, and incised. The
peritoneal cavity was entered with S retractors and a 12-mm Hassan port was then placed, taken care to avoid dissecting into
the falciform ligament. The abdomen was insufflated to 15 mmHg and the 30-degree laparoscope was inserted to confirm
position within the peritoneal cavity and inspect the abdomen. The Hasson port was then secured to the skin with Vicryl
sutures. Additional ports were then placed under direct laparoscopic visualization. A left paramedian port was placed
approximately one hands breadth to the left and slightly lower to the initial cutdown port. Bilateral 5 mm subcostal ports were
placed a hand’s breadth from the paramedian ports. A 5 mm port was placed in the lateral aspect of the right upper quadrant
and in-line with the lower edge of the liver for insertion of the liver retractor. Under direct laparoscopic visualization, the
liver retractor was inserted and used to elevate the left lobe of the liver for exposure of the hiatus.
The patient was placed in steep reverse Trendelenburg position to facilitate visualization of the hiatus. The herniated content
was then reduced gently. The herniated sac was then grasped near the 12’oclock position and everted. Using the harmonic
scalpel, the sac was opened, exposing the areolar plane between the hernia sac and the mediastinum. The sac was sharply and
bluntly dissected from the pleura laterally on both sides, the pericardium anteriorly, and the aorta posteriorly with the use of
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