Referring to the following report, what type of suture was placed at the fundus

Question

Referring to the following report, what type of suture was placed at the fundus of the gallbladder prior to dissection?

BIG RED MEDICAL CENTER

2211 Hilltopper WayBowling Green, KY 42101(270) 123-4567

Operative Report

Patient Name: Jeanne Waters Patient Number: 67-53-22

Date of Birth: 04/23/1936 Room Number: 323

DATE OF PROCEDURE: 05/04/20XX

PREOPERATIVE DIAGNOSIS: Acute cholecystitis with cholelithiasis

POSTOPERATIVE DIAGNOSIS: Acute purulent cholecystitis with gangrenous change in wall and early perforation and localized peritonitis

PROCEDURE PERFORMED: Cholecystectomy with operative cholangiography

SURGEON: Robert E. Lee, MD

ASSISTANT: E.M. Grant, MD

PROCEDURE: The patient was placed supine on an operating table and a general endotracheal anesthetic was administered uneventfully by Dr. Morse. The abdomen was prepared with heavy cleansing alcohol. The operating field was draped in sterile towels and sheets. A primary right subcostal incision was used in this very large (about 250 pounds) patient with an extremely generous incision.

Upon opening the peritoneal cavity, it was noted immediately that the gallbladder was quite inflamed and the omentum was packed around it. There was fibrinous exudate overlying parts of the omentum but this could gradually be released revealing a markedly thickened and reddened gallbladder consistent with acute cholecystitis. In addition, on its medical portion of the wall, there was a gangrenous area that showed evidence of perforation and a purulent collection of about 25 cc of materials as well as the fibrinous exudate. This was cultured for aerobic and anaerobic organisms. The gallbladder was released from the gallbladder fossa starting at the fundus and working to the neck, and because of the intense inflammation, this patient had marked vascular changes in the liver bed. These were packed away as dissection proceeded with which could be done essentially with a finger until reaching a thickened area at the neck of the gallbladder. In this portion, very careful and gradual blunt dissection was performed identifying the cystic artery which was clamped, divided and doubly ligated with 2-0 Tevdek and then clipped with a metallic staple.

The cystic duct was identified. In this patient, it was quite short measuring not more than 10 mm in length and extending into the common duct which could be visualized below and the common hepatic duct above. The neck of the gallbladder was tied with 2-0 Tevdek. The cystic duct was opened. Common clear bile escaped. Two operative cholangiograms using half strength radiopaque dye of about 10cc each injection were obtained showing no evidence of filling defects and ready entrance of dye into the duodenum. The cystic duct was then clamped and doubly tied with the 2-0 Tevdek adjacent to the common duct but not impinging on it. As  the films were being developed, the rest of the gallbladder was being released by blunt dissection and totally removed intact.  Not mentioned previously was that it was first decompressed before dissection was performed placing a purse-string suture at the fundus and releasing all the purulent bile with a trocar and this bile was also cultured for aerobic and anaerobic organisms.

Now going on, the operative areas were inspected gradually and slowly, and hemostasis obtained with electrocoagulation. Unfortunately, our coagulating mechanisms sent off alarms apparently from her pacemaker or the right hip prosthesis so that several of these were tried. Fortunately, a satisfactory connection could be obtained and electrocoagulation proceeded to a satisfactory level.  In this patient, the liver was quite friable throughout. In all areas where there were raw surfaces, either Gelfoam or Surgicel packs were placed and hemostasis appeared secure when all of this was completed.

The operative areas were lavaged with copious physiologic saline, returns were clear. Two one-inch Penrose drains were placed in the infrahepatic space and brought out through a separate inferior stab wound. The intestinal contents were replaced.

In view of the findings described, a general exploration was not performed in this patient except to note there was no evidence of acute disease within the duodenum or distal stomach which was decompressed with a nasogastric tube during the procedure.

The abdomen was closed in layers using running #0 Vicryl and the peritoneum and fascia supplementing the anterior fascia with interrupted #0 Vicryl, interrupted 3-0 Vicryl in the subcuticular tissues and metallic staples in the skin. Lavage of all layers was performed with physiologic saline as closure was accomplished. Appropriate dressings were applied. Sponge, needle and instrument counts were correct.

ESTIMATED BLOOD LOSS: Blood loss was abdominal about 700 cc because of the inflammatory findings described.

The patient’s vital signs remained quite stable throughout and she was transferred to the Recovery Room in satisfactory condition

________________________

Robert E. Lee, MD

REL/ks

D: 05/01/20XX

T: 05/02/20XX

A. Mattress

B. Purse-String

C. Figure-of-eight

D. Interrupted

Explanation / Answer

B. Purse-String

From the procedure description, it is clear that it was first decompressed before the dissection was performed, placing a purse-string suture at the fundus and released all the purulent bile with a trocar.

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