45
© Springer Nature Switzerland AG 2019
D. J. Papandria et al. (eds.), Operative Dictations in Pediatric Surgery, https://doi.org/10.1007/978-3-030-24212-1_12
Placement of Gastric Electrical
Open
1. Laparotomy
2. Intramural securement of leads at the gastric antrum, with or without simultaneous endo- scopic visualization
3. Connection of leads and initial programming of stimulator generator
4. Formation of subcutaneous pocket and place- ment of stimulator generator
5. Closure of incisions
Note These Variations
• Intraoperative endoscopy can be used to con- firm intramural placement of permanent leads and avoid violation of the gastric mucosa as leads are advanced.
• Dictation reflects placement of an Enterra II (Medtronic, Minneapolis, MN), but other approved gastric neurostimulator products can be utilized.
• The presence of a gastrostomy, gastrojeju- nostomy, or diverting enterostomy requires careful exclusion of these sites from the operative field as well as possible adjust- ment to port placement and generator siting to avoid contamination of the implanted device.
• Generator replacement for battery failure is typically performed locally, without the need to obtain intraperitoneal access or adjust lead placement/positioning.
Template Operative Dictation (Endoscopic)
Preoperative Diagnosis Impaired gastric emptying
Postoperative Diagnosis Same as preoperative diagnosis
Findings Same as postoperative diagnosis
Procedure(s) Performed 1. Upper endoscopy
2. Temporary Placement of gastric electrical stimulator with nasogastric leads
Anesthesia General/procedural sedation
Specimen None Drains None Implants
1. ____ gastric neurostimulator generator, Serial number: ____
2. ____ neurostimulator multi-polar lead, Serial number: ____
Estimated Blood Loss None
Indications This is a/an ___-year-old male/
female with impaired gastric emptying second- ary to ____. He/she was evaluated and deemed to be a suitable candidate for temporary place- ment of gastric electrical stimulator to assess potential benefit prior to placement of an implanted device.
Procedure in Detail Following satisfactory induction of anesthesia/sedation, the patient was placed in supine position and appropriately pad- ded. Timeouts were performed using both pre- induction and pre-incision safety checklists with participation of all present in the operative suite.
These confirmed the correct patient, procedure, operative site, and additional critical information prior to the start of the procedure. The patient was then fitted with a bite block.
A flexible gastroscope was introduced per oris, traversing the pharynx and esophagus under endoscopic vision to access the stomach. All visualized structures were unremarkable with the exception of ___. A site for stimulator lead place- ment was identified along the anterior greater curve and the temporary lead was introduced per the left/right naris and advanced blindly/under
47
endoscopic vision until the electrode tip reached the site of interest.
[Choose One:]
If securing with ties and clips: The multi- channel stimulator lead was then prepared for insertion by fashioning loops in a 2-0 silk tie and tying this to the distal end of the lead. Care was taken not to obstruct the contact electrodes present in the dis- tal lead housing. The lead was then secured using the endoscopic clip applier, affixing the silk loops to the gastric mucosa at four points.
If securing with clips alone: The mucosa was then imbricated over the tip of the lead using the endoscopic clip applier, completely covering the electrodes.
The lead placement was then inspected and found to be satisfactory. The lead terminals were then connected to the generator and inter- rogated using designated equipment provided by the manufacturer, verifying impedance (___
Ohm) and current within goal range. The gen- erator was then programmed with the following settings:
Voltage: ___ V Pulse window: ___ ms Time on: ___ sec Time off: ___ sec Frequency: ___ Hz
Insufflated gas was then aspirated, endoscopy terminated, and the endoscope removed. Upon completion of the procedure, a debriefing check- list was completed to share information critical to the postoperative care of the patient. The patient tolerated the procedure well, was extubated in the operating room, and was transported to the post- anesthesia care unit in stable condition thereafter.
Template Operative Dictation (Open)
Preoperative Diagnosis Impaired gastric emptying
Postoperative Diagnosis Same as preoperative diagnosis
Findings Same as postoperative diagnosis Procedure(s) Performed
1. Placement of gastric electrical stimulator (left/right-sided)
2. Upper endoscopy
Anesthesia General/procedural sedation
Specimen None Drains None Implants
1. ____ gastric neurostimulator generator, Serial number: ____
2. ____ neurostimulator leads, Serial numbers:
____, ____
Estimated Blood Loss None
Indications This is a/an ___-year-old male/
female with impaired gastric emptying secondary to ____. He/she was evaluated and deemed to be a suitable candidate for open placement of gastric electrical stimulator by clinical criteria/following trial of a temporary stimulator.
Procedure in Detail Following satisfactory induction of anesthesia, the patient was placed in supine position and appropriately padded.
Timeouts were performed using both pre- induction and pre-incision safety checklists with participation of all present in the opera- tive suite. These confirmed the correct patient, procedure, operative site, and additional criti- cal information prior to the start of the proce- dure. The abdomen was then prepped and draped in the usual sterile fashion and an Ioban impermeable drape was applied. A site for subcutaneous placement of the stimulator gen- erator was identified and marked in the left lower quadrant.
12 Placement of Gastric Electrical Stimulator
A/an ___-mm midline/left paramedian inci- sion was placed and carried down to the level of the fascia using electrocautery laparotomy. This was then divided using electrocautery, proceeding to the peritoneum. This was placed on anterior traction and sharply incised, then opened along the whole of the incision using cautery. A cursory inspection of the intraperitoneal contents revealed no traumatic sequelae of abdominal access.
[Choose One:]
If using intraoperative endoscopy: The patient was fitted with a bite block and simultaneous flexible endoscopy was then performed. A flexi- ble gastroscope was introduced per oris, travers- ing the pharynx and esophagus under endoscopic vision to access the stomach. All visualized struc- tures were unremarkable with the exception of ___. The site for stimulator lead placement was confirmed and maintained under endoscopic sur- veillance. The gastric mucosa was observed endoscopically during lead placement and this was not violated. Insufflated gas was then aspi- rated and the endoscope removed on completion of lead placement.
The guide suture was placed longitudinally within the gastric wall using a needle driver.
Gentle traction was then applied to the suture to draw the attached electrode into proper position.
This was repeated to place the second lead. The leads were then transfixed to the stomach by placing interrupted 0 Ethibond first bilaterally through the silicone retention flange on each lead, then taking seromuscular bites of the adja- cent antrum. Silicone retention discs were then introduced per the port and the guide sutures were passed through the center of each. Both discs were then secured to the stomach with bilat- eral interrupted 0 Ethibond sutures in similar fashion to the flange. Finally, each lead’s reten- tion suture was fixed at the level of the disc using the medium clip applier. The exposed segments of the guide sutures were then transected and the needles removed from the peritoneum.
A 6-cm transverse incision was placed at the previously identified site for generator placement in the left lower quadrant. This was carried down through the skin and subcutaneous tissues to the
level of the fascia using electrocautery. The extra- peritoneal segments of the leads were then tun- neled to this wound bed. The pocket for the stimulator was developed using a combination of blunt dissection and electrocautery along the anterior fascia inferior. On completion, this accommodated the implant without tension of the overlying skin.
The laparotomy incision was then closed in layers, starting with interrupted 0 Vicryl for the fascia leaving a 3-mm defect for the traversing leads. This was followed by closure of the deep dermal layer with interrupted 4-0 Vicryl and skin closure with 5-0 Monocryl in continuous subcu- ticular fashion.
The device to be implanted was then con- nected to the leads and interrogated and then dis- abled using designated equipment provided by the manufacturer, verifying impedance (___
Ohm) and current within goal range. The genera- tor was then programmed with the following settings:
Voltage: ___ V Pulse window: ___ ms Time on: ___ sec Time off: ___ sec Frequency: ___ Hz
The device was then deactivated to permit the use of monopolar cautery and placed within the subcutaneous pocket. Redundant lead wiring was coiled and placed behind the generator within the pocket. The wound was then closed in layers, using interrupted 3-0 Vicryl for Scarpa’s fascia, interrupted deep dermal 4-0 Vicryl sutures, and skin closure with 5-0 Monocryl in continuous subcuticular fashion. All incisions were then dressed with surgical skin adhesive. The device was re-interrogated and activated following con- firmation of acceptable lead impedance.
Upon completion of the procedure, a debrief- ing checklist was completed to share information critical to the postoperative care of the patient.
The patient tolerated the procedure well, was extubated in the operating room, and was trans- ported to the post-anesthesia care unit in stable condition thereafter.
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Template Operative Dictation (Laparoscopic)
Preoperative Diagnosis Impaired gastric emptying
Postoperative Diagnosis Same as preoperative diagnosis
Findings Same as postoperative diagnosis Procedure(s) Performed
1. Diagnostic laparoscopy
2. Laparoscopic Placement of gastric electrical stimulator (left/right-sided)
3. Upper endoscopy Anesthesia General Specimen None Drains None Implants
1. ____ gastric neurostimulator generator, Serial number: ____
2. ____ neurostimulator leads, Serial numbers:
____, ____
Estimated Blood Loss ___ mL
Indications This is a/an ___-year-old male/
female with impaired gastric emptying secondary to ____. He/she was evaluated and deemed to be a suitable candidate for laparoscopic placement of gastric electrical stimulator by clinical crite- ria/following trial of a temporary stimulator.
Procedure in Detail Following satisfactory induction of anesthesia, the patient was placed in supine position and appropriately padded.
Timeouts were performed using both pre- induction and pre-incision safety checklists with participation of all present in the operative suite.
These confirmed the correct patient, procedure, operative site, and additional critical information prior to the start of the procedure. The abdomen was then prepped and draped in the usual sterile
fashion and an Ioban impermeable drape was applied. A site for subcutaneous placement of the stimulator generator was identified and marked in the left lower quadrant.
A 5-mm umbilical incision was placed and carried down to the level of the fascia using blunt dissection. The abdomen was entered, followed by placement of a 5-mm trocar. The abdomen was then insufflated to a pressure of 15 mmHg and the laparoscope was introduced into the peri- toneal cavity. A cursory survey of the abdominal contents revealed no traumatic sequelae of abdominal access. Local anesthetic infiltration and stab incisions were then placed at two addi- tional trocar sites: a 5-mm port was placed in the left upper quadrant and a 10–12 mm port in left lower quadrant under laparoscopic vision. The incision for the latter port was placed at the previously marked generator site; this was extended transversely by 5 cm and carried down to the level of the fascia with electrocautery. The fascia was divided with electrocautery and the abdomen entered bluntly with a hemostat. This was replaced with a Veress needle within a dilat- ing sheath, which was then used to insufflate the abdomen to a pressure of 12 mmHg, and this was well tolerated. The needle was removed and a 5-mm radially dilating port was placed per the sheath and a 5-mm laparoscope introduced into the abdomen. A cursory laparoscopic examina- tion of the intra-abdominal contents revealed no traumatic sequelae of abdominal access. Local anesthetic infiltration and stab incisions were then placed, followed by placement of 5-mm radially dilating ports in the left lower quadrant and left upper quadrant. Finally, the umbilical port was replaced with a 10–12 mm radially dilating port and all port placements were per- formed under laparoscopic vision.
The two stimulator leads were then introduced per the left lower quadrant port and positioned to lie without tension on the stomach at favorable sites on the anterior gastric wall.
[Choose One:]
If using intraoperative endoscopy: The patient was fitted with a bite block and simultaneous
12 Placement of Gastric Electrical Stimulator
flexible endoscopy was then performed. A flexi- ble gastroscope was introduced per oris, travers- ing the pharynx and esophagus under endoscopic vision to access the stomach. All visualized struc- tures were unremarkable with the exception of ___. The site for stimulator lead placement was confirmed and maintained under endoscopic sur- veillance. The gastric mucosa was observed endoscopically during lead placement and this was not violated. Insufflated gas was then aspi- rated and the endoscope removed.
The guide suture was placed longitudinally within the gastric wall using a laparoscopic nee- dle driver. Gentle traction was then applied to the suture to draw the attached electrode into proper position. This was repeated to place the second lead. The leads were then transfixed to the stom- ach by placing interrupted 0 Ethibond first bilat- erally through the silicone retention flange on each lead, then taking seromuscular bites of the adjacent antrum. Silicone retention discs were then introduced per the port and the guide sutures were passed through the center of each. Both discs were then secured to the stomach with bilat- eral interrupted 0 Ethibond sutures in similar fashion to the flange. Finally, each lead’s reten- tion suture was fixed at the level of the disc using the 5-mm clip applier. The exposed segments of the guide sutures were then transected and the needles removed from the peritoneum. The extra- peritoneal segments of the leads were then deliv- ered through the left lower quadrant port, which was then removed.
The remaining port was then removed under laparoscopic vision and site was noted to be hemostatic. Following desufflation of the abdo- men, the 5-mm sites were closed at the fascia using interrupted 3-0 Vicryl and 10–12 mm site using 2-0 Vicryl in similar fashion, securing the leads. The pocket for the stimulator was devel-
oped using a combination of blunt dissection and electrocautery just superficial to the anterior fas- cia inferior to the incision in the left lower quad- rant. On completion, this accommodated the implant without tension of the overlying skin.
The device to be implanted was then con- nected to the leads and interrogated and then disabled using designated equipment provided by the manufacturer, verifying impedance (___
Ohm) and current within goal range. The genera- tor was then programmed with the following settings:
Voltage: ___ V Pulse window: ___ ms Time on: ___ sec Time off: ___ sec Frequency: ___ Hz
The device was then deactivated to permit the use of monopolar cautery and placed within the subcutaneous pocket. Redundant lead wiring was coiled and placed behind the generator within the pocket. The wound was then closed in layers, using interrupted 3-0 Vicryl for Scarpa’s fascia, interrupted deep dermal 4-0 Vicryl sutures, and skin closure with 5-0 Monocryl in continuous subcuticular fashion. Skin at the port sites was then closed in a similar fashion. All incisions were then dressed with surgical skin adhesive.
The device was re-interrogated and activated following confirmation of acceptable lead impedance.
Upon completion of the procedure, a debrief- ing checklist was completed to share information critical to the postoperative care of the patient.
The patient tolerated the procedure well, was extubated in the operating room, and was trans- ported to the post-anesthesia care unit in stable condition thereafter.
51
© Springer Nature Switzerland AG 2019
D. J. Papandria et al. (eds.), Operative Dictations in Pediatric Surgery, https://doi.org/10.1007/978-3-030-24212-1_13