Laparoscopic-Assisted Takedown of a Gastrocutaneous Fistula

CHAPTER 1

I'm Eric Pauli, a Professor of Surgery at the Penn State Hershey Medical Center in Hershey, Pennsylvania. Today we're gonna do a case, which is a patient who has a gastrocutaneous fistula. She's a 27-year-old who as an infant had an open Nissen fundoplication and a G-tube placement to manage some other chronic medical problems, including some cardiac issues. She had the G-tube for several years and it was taken out and for many years there were no problems. About two years ago, she developed an infection of the abdominal wall and x-rays suggested that she had a reopening of the fistula tract. There was infection in the subcutaneous space. She had an attempted endoscopic closure at an outside facility, which unfortunately failed. And since the tract had opened up and drained several times, she was referred to me for evaluation. She and I talked about whether we should try an endoscopic intervention again or whether we should go forward with a surgical procedure. And given that she'd had symptoms for several years, it's a 27-year-old tract, and she'd already failed endoscopy once, she elected to go forward with a surgical intervention today. Our plan is a laparoscopic takedown of the gastrostomy, which is kind of a hybrid, part of it is gonna be open because we do need to remove the entire fistula tract from the skin all the way down through the rectus muscle. So the first half will be laparoscopic. The second half will be more or less an open procedure. And then we'll do some closure of the abdominal wall. In the middle of it, we're gonna do an endoscopy as well so that we can check and make sure there's no bleeding from our gastric staple line and also no leak.

All right, this is a CAT scan from our patient with a gastrocutaneous fistula. As we work our way down through these axial cuts, you can follow her esophagus down into her stomach where there's a Nissen fundoplication. These radiopaque areas right here are the pledgets that we know that she has. And on our previous endoscopy, the team saw some of those pledgets eroding. So we may find some of those today as we do the procedure. As we follow the stomach down here, we can see where the fistula tract is located. Here is the stomach being pulled into the body of the left rectus abdominis muscle. And this was taken at a time two years ago when she had an active abdominal wall infection. And you can see inflammation in the subcutaneous tissue as well as air tracking around it. So there was an active infection as the fistula was opening back up. As we come in today, our goal is to try to work the fistula down so that we are taking a stapler load and dividing this part of the stomach only. We don't wanna take a huge wedge of the stomach, if possible. And then we'll do an open procedure and take the skin, the subcutaneous tissue, all the way down through the abdominal wall to this tract. So we'll core this part of the abdominal wall out. We will close the fascia and we'll close the skin loosely and then pack to reduce the risk of infection. So that's our plan for the day today. I typically do a Hasson entry and so we'll go in here at the umbilicus. This is close-ish to where we're going to be working. There should be enough room though for this to be a usable port for our stapler to go in to then staple across the fistula tract right here.

CHAPTER 2

So we'll do a little field block. A little field block. We'll go infraumbilical to give us a little extra centimeter away from that potential scarring. It also gives you, if you're gonna put your stapler in here, you need a little bit of room to kind of get up there and work. Yep.

CHAPTER 3

Needle back. Let go for one second. Yeah, that's okay, it should be okay there. I'm gonna grab it. There-ish. Yep, there you go. Incision. I'll take it Kelly. Wonderful. Get the deep dermal stuff uncut. You can go a little more your way. There you go. Good. Okay. So every human has this little midline raphe thing in them. I don't know why or how or what it's called or it's not in any textbook, but there it is. It's there every time. I'll take a Kocher. Get a Kocher below me. Yep. I'll take a, I'll take another Kocher. There's some fascia there. Beautiful. Take a knife. Go more wide than deep. You just kind of want to get a 12-port in. And you wanna see a little bit of preperitoneal fat. Yeah, a little deeper. Hold on, let's see what we got there. You just barely got it, there we go. Right there, good. There's some fat. Go a tiny bit more in that corner. She's, you know, young and she has good fascia. Watch your tip... There's some preperitoneal fat there. And we're in. Nope, give her a 0 Vicryl on a UR-6. Let that guy go. Give her a snap as well. A curved snap. You'll palm the curved snap in your left hand. Yep. Just push the skin back. You'll do a U-stitch from the outside. So push the skin back. There you go. There's your first bite, there to there. I'm gonna get under the fascia. I'm gonna show you the bite. But once you get in and engage the fascia, I'm gonna get outta your way. So come in and under, stay there. I'm gonna get outta the way. Just engage the fascia and then roll through. This time you're gonna go under the fascia 'cause that is what works better. So you're gonna do another U on my side, but you go under the fascia this time. And oftentimes I'm in your way again. So just kind of come in and under, disengage the fascia and I'll get outta your way. You're in and under, I'm outta the way. There's your bite, needle off. And we'll snap here. You got the Hasson ready to rock there. Sometimes you actually close the peritoneum accidentally when you do that. Make sure we still have a nice little pathway in. See, we've closed it a little bit. So it's a little bit, it's kind of downward. Stretch this a little bit more here. There you go. That looks better. May have just caught the corner. You know that sometimes those ridges catch the suture, not worried. Okay good. Gas on please. You can go right to high flow. We're gonna insufflate. Yeah, high flow's fine. The pressure's set at 10. Leave it at 10 for now. We'll leave it that way as we insufflate up here. We don't over pressurize or there's some bow wow there. We'll just give it a second to come up to pressure. It'll take a little bit longer 'cause we're only going at 10 here. She's tolerating, we're at pressure now. She's tolerating that, let's go to 15 on the pressure then. Cici, what's the first thing we do when we get in? Look around? For? Pull this back. If we perforated the bowel by some misfortune. We just wanna look for injury. So we're gonna just gonna look straight down and we're gonna just kind of go in. We're just gonna kind of do a little spinning maneuver 'cause it's a 30-degree lens. We'll do a little, a secondary spin. That all looks fine. Now there's a liver and there's some adhesions there. So we're close to the adhesions, which we anticipated on the midline. We can back that port out more. That's fine right there. Lock it there. And we're at 15 pressure. Okay, fine. Let's get a little more slack on that cable. All right, so it's gonna be mostly body of stomach that's gonna be stuck here, hopefully. Let's take a look, there's some small bow wow. That's some omentum stuck there. And again, there's gonna be a lot of stuff stuck because of the inflammation. That's probably the body of the stomach right there. Okay, so let's get some additional ports in here and let's start taking down this omentum. Going up to that area, again, it's probably the stomach. There's the lever stuck up. That's gonna be stomach stuck up there. Where's colon? That's colon. That's colon down. So the colon looks like it's, and that's gonna be colon down there. Okay, let's think about port position. Okay? Like this is straight on to these adhesions. So that's a usable working port. We can go here and here. Boom and boom. Have a camera center and a working hand here or a camera here and two working hands here. We kind of wanna work this direction anyway. This would be an a good additional assist port if we need it. But I don't think we need it right now. I think we can kind of do you know here and here. Wanna do that? Well let's take a look here. Is she fully relaxed? There's a round ligament and no inguinal hernia there. Oh well look at that guys. Do you see that? What do you guys see? Cici what do you see? That's the round ligament going through the abdominal wall. What is it? It's the world's tiniest inguinal hernia. When we get some hands in, we'll pull that flap aside. We're also gonna look at this side and and pull. This is what you would call in a female patient a hided in hernia. You know, some people present with symptoms there and when you scan them there's absolutely nothing. You don't see anything when you examine 'em. You don't really feel anything either. But when you look with the scope you sometimes see them.

CHAPTER 4

So you wanna do your upper, where's your - rib cage is there. She's actually, she's really tiny huh? Let's take this off. There's your hip there and a rib there. You'll be able to get, you can kind of do I think sort of there and there will work something like that. You know, again we can, we can struggle with some hand clashes. Just do your upper one first. You know, stay off the costal margin. Give yourself some room. Give me a push with a finger so I can find you. Yeah, that's gonna be fine right there. Come on in. Can we dim the room lights a little bit? Let's go to perimeter lighting. Knife and then a five port. Yep, lots of twisting, a little bit of pushing. Easy on the colon. Good tissue. All right, go back to that side and take a look here. Just make sure this port looks okay. I almost always in cases look back at this port even when you're sure it went in just fine. Because you can do all sorts of goofy things. I one time did an entire gallbladder surgery with a port through the small bowel mesentery. It looked fine. We couldn't see anything, and then we looked back. Okay, so this, so look, just, just look. If we use this port, we might struggle initially there just for a micron to get that down. But that's all safe to take down and that'll head all the way back up. So then I think that another hand probably somewhere in between these guys like here is gonna be the way to go. I'll take the camera here. Just try and make sure we're outside the semilunar line. Wheres her...? That's probably right at it. Can you go just a micron more lateral? Yeah, this will be another five port. We need the obturator. That's a different port guys. Give Tori a bullet. Come on in. Let's go down to the left lower quadrant. Just come underneath me there. Yep, advance down. There you go. Let's take a look at that hernia. Okay? Just grab the peritoneum. You can even grab the round ligament and pull. Yep. Grab the far side peritoneum, pull it open the other direction. So pull towards the patient's... Yeah, I mean there's an actual, there's an actual little space there. It probably goes farther than you think. Let go for a second. Yeah, it definitely goes down. Sometimes if you have the inguinal canal open, you can actually see the air tracking down. Yeah, it goes a little farther than you think. I mean it's not a real hernia. We're not gonna do anything about it. But you can see the defect, right when you pull, you can see the fascial defect that's there. Pull it again and watch the hole in the abdominal wall. And then let it go. See it slide back through? So there's a legitimate defect there. But again, that's for another day. All right. Give her that obturator and the port. Lots of twisting, a little bit of pushing, yep. Easy on the colon. Okay, fine. Let's put the camera on one of your spots there. I'll come over to that side and drive. And then she's gonna need probably a bullet in the harmonic. Yep, where do you want me? I can go like this. You wanna work over the top? We have a little bit of head up positioning. Head up and berg. I get this view better as well. We're making a movie. I'll take a fresh Raytec there. Okay.

CHAPTER 5

Yeah. You're gonna struggle a little bit with that port for initial takedown. Again, if we need to, if you need to do it from the other side, you certainly can stay as high against the abdominal wall as you can. Yep, torque it up. This will be a little awkward to start and then we'll be okay. Go for it, that's all safe. Yep. Okay, get a little blunt dissection now, see what you get. Just give it a little sweep. Okay, cut the clear stuff. Yep, I would take the near edge now. The stomach's gonna start to show up there. So there's a near edge and a far edge of the adhesion. I would just start on the near edge there and again you can bluntly sweep, if you wanna change hands as well if it's easier to do opposite. Don't be afraid to do that, yep. It is, again, once you're, this is gonna be the hardest part. Yeah 'cause we're close to the target. Okay? You have a little sweep there. You start to think about where's the actual stomach here. Okay? We know it's embedded in the abdominal wall somewhere. So start on the near edge and then work to the far edge. Stay as high as you can on that abdominal wall. Stay way up there if you can. I like that, yep, good. See where her falci is as well. Yeah, that'll work, do it like that. There you go. Yep. Yep, take the near stuff. Uh-huh. That's all fine to take. Let's take the next layer of stuff here. Yeah, I got all that clear stuff, that's great. Sweep down, yep, there you go. Good. Nice. There's some stomach there. Fine. And then let's just push where the finger and see where our fistula is gonna be roughly. Okay, so that's gonna be where the fistula is. Okay. So I think a lot of this in the midline then is just, you know, when she had a laparotomy, this is all just adhesions to the laparotomy. There's the stomach right there. Okay? So let's work all this down 'cause we need a window above and below the stomach to be able to fire a stapler. At a minimum, that's what we need, at a maximum, we'd like it all the way down so that as we're working on the abdominal wall, we can use the LigaSure here. And again, we've got the scan. We know that between the liver and the stomach, they're pretty much plastered together on the scan. And here they are plastered together in real life. I would take that bite. So again, this is gonna be, that's gonna be fistula central right in there, okay? So I would just, you know, take those little bites, you know, with some caution, if the whole stomach is stuck up, you've gotta get it down on the backside because then you're gonna be firing a stapler for forever, right? You want a staple line that just takes the fistula down. Let's see what's up there, okay? So that's where you were working. And here's the backside, so there's adhesions to the liver there, there's the colon there. That's the liver. Is this the stomach here or the colon? We think it's the stomach 'cause that's the stomach there, right? Give that a big push, there you go. Yeah, that's all the stomach pushed up. So look, we need to, so the backside is reasonably free, but we need to really kind of work a window down, okay? So what we should do, again, we gotta figure out where the fistula is and if we need to stick the endoscope in to do that, we can also stick the endoscope in and drive up into the fistula. But as we push it's kind of, it's kind of thereish. There's a stitch there. See it? See the stitch right there. I think it goes up into the abdominal wall probably right about there. There's actually a defect in the abdominal wall right about there. So there's a pexi stitch there that'll need to come down and we'll need to kind of get that stuff down there and then it's gonna be stuck. So let's try and work up above on the top part there. Okay. I think it's better if I work from these two. Our pressure is five. Can you hit start on the gas please? So what I'd like you to do is let's work up here somewhere where there's a little bit of a fatty plane and let's try and swim across, we wanna get the stomach down off of the abdominal wall above. But we need to stay above the gastropexy sutures. Okay? So that's okay to take down. Some of this is gonna be okay to do bluntly. Very likely. Lemme clean the camera once we do this. All clean. Yeah. So just kind of, you know, get your two instruments in to kind of swim that down. Swim, swim, swim. Push, push, push. And again, if you gotta take a little bit of peritoneum with you, that's okay. The stomach is gonna stick back up to it when we're done. If you wanna go to a scissors and just use some cold scissors, that's okay too. That looks like body of stomach there. There's a little bit of a clear window there. I think that's abdominal wall. So just get some lap scissors, take care of the device back while you're waiting. You know, goal is not to burn the stomach. Stay off the stomach. There you go. Yeah, watch that back jaw. Yep, gentle, gentle. But it looks like it's coming down. You got those shears ready for us. We know that there's a fundoplication up top and we know that her pledgets are actually eroded into the lumen. You're gonna have a window around that is gonna be able to, you'll be able to get through.

CHAPTER 6

So why don't you take down the stomach now with your cold shears. Okay? And just kind of work from the top edge up to where we think the fistula is. The disposable scissors are both sharp and pointy, which I don't like 'cause it's easy to poke 'em into things. During enterolysis, it's very easy to poke the tips in. Grab over the top a little bit. Again, as you get closer to where the fistula is attached to the abdominal wall, you're more likely to injure the stomach because it's attached to the abdominal wall. But also we're gonna staple that off and remove it. The other thing is sometimes one of those stitches is actually in the fistula tract, like up in the abdominal wall and you don't even notice it until you're up there taking the whole thing out. Nice. Okay, you're getting there. I'm gonna change the view. So I'm not sure exactly what that is. Let's take a look. Go in all the way around, let's go this direction, da da da. Let me come in and go in and up. Yeah, that's all clearly stomach. The question is like there's a gastropexy stitch close, like there's a stitch right there for sure. Right? That's definitely a stitch. The fistula is there. Got a good grab on that stomach. Let's see what moves off the abdominal wall. Yeah, you know you can kind of snip in the abdominal wall there. Yeah, there. And even from the down edge. I think the body of the stomach is a little bit lower than you think. Yeah, that's okay there. We're just gonna stop operating until the scissors are here, okay? Sweep that way, yep. You wanna try and get a little more of that down going that way? You know again, do you have enough down to get a stapler on the upside? You know for sure, okay. It'd be nice to have again this, I'd like to get this section from here to about there down. And again, depending on how they did the gastropexy, there may actually be after the stitch, there actually may be a clear or a clearer window in there somewhere. If you start firing a stapler now, you can see how much of the stomach you're gonna have to wedge off. Put your instrument in over the top. Again, if we need a port on the left, we're gonna put a port on the left. Some of that's clear and we'll start to fall down as we start to get the stomach down a little bit. See what you can tease out here. Any of that takable. Well again there's a stitch nearby and so it's hard to, it's hard to say, I mean the body of the stomach is back there. Rotate your hands. Make the ceiling the ceiling. Rotate more, there we go, yep. So there might actually be a little bit of a window kind of here-ish where the stomach is stuck here to the edge of the posterior sheath but is able to be kind of, you know, worked through a little bit. If this was a gastropexy stitch, there may be a little granuloma. See a little granuloma right there. Yeah? But I think if we stay very high on this, like if we take this down including the stitch, we can leave it on the stomach. Oh cool, okay. We just need to make sure that we're not, I don't think there's any metal here. I don't recall any metal on the scan. But we can take a quick peek. You know, some people put clips near their gastropexy stitches so they can be found in the future. We just wanna make sure there's no metal where we're firing the stapler. That would be no fun if it misfires. Yeah, that's good, I like that. So I think the stomach is down. Lemme weigh up against the abdominal wall here. I'm on the abdominal wall. That's the stomach there going up into the fistula. That's the body of the stomach there. So I'm gonna take this, again, I'm gonna stay way against the abdominal wall way up here and out of the way. I'll take a Maryland back. That's gonna be a fourth gastropexy on the backside. Somewhere up in there. That's the actual fistula going up into the abdominal wall there. I don't wanna do that. That's gonna tear if I do that. Guys, we're not gonna use the microshears, sorry. Rotate your hands a little bit. Make the ceiling the ceiling for me. Rotate your hands a little bit. Let's come back in here. That's all nonsense stuff. And again, if we need to, if we need to put a port on that side to see, we certainly can. Where do you think the edge of the stomach is here? Probably right about there, huh? So we need to kind of cold shear it like up in there. That's a gastropexy stitch there. This is the backside of the fistula here going up. Let's go right in here. See what we got up in here. Again, there should be a superior gastropexy stitch somewhere in here as well. Can you rotate your hands a little bit? I'm hitting you. Let's see, we can't work like that. It's okay, yep, that'll work. Okay, so this is soft. This can come down. That's gonna be a stitch. Like right there. That's actually a stitch right there. That's a stitch. So that's the fourth. So there's one here. There was probably one in here we already took down. Like right in here. That's two. There's one back here that we can see as three. That means there's gonna be a fourth one way on the backside. Now if that fourth one, if we can't actually see it to take it down, we can fire the stapler across it in that direction. I think that'll be okay. But I don't think we have enough. Like I think this is too much to staple boom right now. I think we gotta keep working this down to be a little bit happier. What's the word on the new stapler guys? The new scissors. Say again? I'll take the scissors. Any of them. Can we look down here together? See if I can grab this edge. I'm hitting you. Okay, let's come to the front side here. Well I'm actually debating just putting a fourth port in and that way we can have the camera maybe there and work two handed along the backside or put the camera on the backside and work from these two ports here. I think that's the stitch there. I'm gonna just take it off the abdominal wall. So is that a stitch right there? Let's take a look. Sort of looks like one. Yeah, right there. With some serosa kind of stuck up. So we're gonna have to take this plane kind of higher up here. Yeah, that's a stitch. Okay. So there's some freedom to mobilize right there. So as I pull, there are some free planes here. So we're kinda looking a little bit around the corner. This is my left hand. Here's my right hand. That's the stitch that we just took down right there. This is the backside of the fistula right here. Maybe. I think it's all adhesion 'cause this looks clear right here. This is a clear space right here. Let's go to the feet, put the camera, put the camera here and let's see if we can see an angle. Just see what it looks like from that spot. Yeah. See so there's that adhesion. That's one of the gastropexies It's gotta come down there. We got the near one down and then past that is that stuff, I say we put another port in and work from the other side. We'll take another five port please. That's outside the semilunar line. So if this were a peg gastrostomy tract, there wouldn't be any gastropexy stuff and you would do a little blunt dissection. I think the fact that she's had multiple repeat infections of the abdominal wall and I mean that last scan, I mean she's got air tracking all over the place. I mean that was a... Well that's why my thought was just to take even the gastropexies, and then when we cut down, like dissect everything out because what if we leave? Well, you can. And I think if we can get an angle to get it down, it's fine. The problem is you don't want to have two gastropexies like this and you're coming across the fistula because what's gonna happen, it's gonna pull the gastropexy. You're gonna have three parts of the stomach, right? You've got stomach, stomach, and fistula. So you really need to be kind of down on the tract. Can I see a bullet? Okay, I'll take a bullet first. So look, if I were a stapler coming from this port, I got a bullet right here. If I were a stapler coming through this trocar, which is how it's gonna come, what would I do? I would come in here like this. I would articulate, now I can come in here. Now come on in with me so I can take this bite right here. Boom. Okay? And that's gonna get a fair bit of it off the abdominal wall. Now that might give us an angle to then work the rest of this gastropexy down from the back. And then we still need to get that gastro. If we fire it across one gastropexy, if we take the fistula and the gastropexy, the back gastropexy in one bite, that's fine. But it's these guys over here that I'm concerned about 'cause we can't have it grab like that 'cause it's gonna be a very goofy firing of the stapler. But this, I mean listen, this is the fistula, we can safely fire a stapler like that if you wanna do that and see what we get, we certainly can. And then we can address whatever's back there with our, you know, we'll have a little better window on the world. Yeah? Yeah. I mean I think either way works if you wanna, if you wanna avoid putting in that other five trocar, we can do that. I mean we need to fire the stapler anyway so it's part of the, let's take a look. Let's let's the stuff here. That's all nonsense. That's the gastropexy, I'll take scissors please. There's the window there. So the fistula is up. This is a gastropexy stitch that I was working down. That's all gastropexy stuff there. Gastropexy stuff there. Let's do a scope now to make sure there is not anything in the fistula tract visibly. Okay? That'll also be our reminder to get the NG tube out. We can then staple across it. We'll have the scope in and we'll immediately do a leak test and a bleed test and then park it there while we do the rest of the stuff, which is dig across the abdominal wall and get the rest of this out. Is that okay? Yep. You wanna come around here and drive the camera so that she can staple? I'll go up and do an endoscopy. What stapler do you want? You want the Ethicon Powered Stapler? Yeah, and then we have blue. I grabbed blue, white, and green loads. I think we could do a blue. It's not crazy thick. The only thing is there is some staple material in there. We can always oversew it. It'll be on the floor to oversew. I think blue should be fine. Okay, let's do it. We'll take the articulating powered stapler 60 and we'll need a blue load.

CHAPTER 7

All right, so there is an ET tube and some cords, you have a successful esophageal intubation. Congratulations. Is it possible to turn the upper bear off for just a few moments so it doesn't stick to my scope and we'll turn it back on as soon as we're done here with our endoscopy. Oh wonderful, thank you. All right. And there is cricopharyngeus there, and I'm now in the esophagus. Now we know that she has a Nissen fundoplication and that the pledgets are eroded. So let's look for the pledgets, which on our EGD they labeled as mesh, question mark. But we don't use mesh in children when we do esophageal stuff. So let's take a look. There are pledgets eroded somewhere in here they said. I don't see 'em. Let's take a look. So there's the fistula right there. I'm gonna just very briefly retroflex to see if we can see the eroded pledgets. There they are. There's a pledget right there, right? That's an eroded pledget from a Nissen. It's kind of scummy looking. Yeah, you know, again, if you had to think about what should a Nissen look like on retroflex, this is a nice view. It should look like sort of a stack of coins. Like one, two. You can see the little folds in the stack of coins. One, two, three stack of coin appearance. You've got a lot of intra-abdominal esophagus. Okay, so would you double check her paralysis for us? I'm insufflating. And if I'm insufflating and the pressure alarm is going off, it might mean we have a leak somewhere. So let's take a look. Go take your camera and drive up to the site there. And look if we see any bubbles or anything, I didn't see anything. It could also be she's a little light on anesthesia or that I'm stimulating her by having a scope in her esophagus. But if I'm insufflating and the pressure alarm is going off, you gotta at least think about that. Doesn't look terrible. Okay, so there's a very eroded pledget there. I only see one. Prolene suture attached to it. Okay, that's gonna stay for the day today. Okay, so I'm coming back outta retroflex. Let's go look at the fistula now. Heading on down, heading on down. Looking at the fistula, so I'm gonna go into the fistula tract. There it is there. I'm in the fistula tract there. It looks okay. I don't see any bubbles or anything. I don't see any metal here in the tract, okay? It looks like a clean fistula tract. Okay, so I'm gonna bring the scope back and I'm gonna decompress the stomach now as much as it can. How's that looking? Okay, good. So now you're gonna wanna get a bullet and your stapler and let's get this stapled off. Okay? I would probably put the bullet above. Yeah, that's the maneuver.

CHAPTER 8

Come on. Okay, I've got CO2. And you're hugging the abdominal wall there real high. Okay, I like it. Lock it down. Make sure your tip is passed, it is. That looks pretty good. Good, okay. Give it a few minutes there. Do your thing. Do we have laparoscopic needle drivers around if we need 'em? Theoretically if you read the instructions for use, they recommend doing this. Is it absolutely mandatory? No. All right, at your leisure fire in the hole. Get your sciss. Very nice. Stay high. There you go. All right, so the near end of your staple line is a tiny little bit of ooze there. Check that out. Yeah, go to two bullets now and then probably what we should do. So just pinch that for a minute. That should be okay. We can always get a clip if you wanna put a clip on the corner there. What we should do then is probably move the camera to the center console there so we can look at the entire staple line while we insufflate. Okay?

CHAPTER 9

So we'll do a little leak test now. We'll make sure it's not bleeding. You have a good grab there. All right, how's it looking? It looks pretty hemostatic. I don't see a need to put a clip anywhere. I'm going to re-insufflate here. We'll look at the inside for bleeding. I'm laying on the gas. It's gonna start to blow up a little bit coming in. How's it looking on your side team? Looks good there. My side looks good here. That's the staple line right there. Okay? Can you tap the patient right of the staple line? Now tap patient left of staple line. I mean look at the inside view guys, right? I mean it's barely even visible. Okay, that looks good. Now the last thing, I mean obviously not obligated to do, but we do do is to go downstream and prove that you have gone past and you haven't narrowed the body of the stomach. Okay? Again, it's pretty obvious that we haven't but we'll do it for good measure. This is the duodenum, that looks empty. I'm gonna suction everything out, and I'll leave the scope in in case you wanna do a little leak test at the very, very end after we do everything else. But I'm pretty happy with that. Everybody good? Good. That's all decompressed, so leave that alone. That looks great.

CHAPTER 10

Okay now it's time to do the open portion of today's procedure. You wanna put some local around the G-tube site there. And we'll start ellipsing that out. Get a little skin marker and mark how much you want to take as well. We're gonna need a number 1 Prolene for the fascial closure, probably on a CT-1. And then we have a suture, a lap suture passer available if we need it. Don't open it yet 'cause I don't know how we're gonna close the fascia, whether it's gonna be open or lap. How do you wanna handle the skin? My thought was maybe like one stitch in the middle to kind of approximate deep dermal and then maybe some wicks on both sides. I would probably not do a staple just so she doesn't have to come back at two weeks to have a staple out. But maybe like a deep dermal stitch and then some packing in the middle. I'd be okay with that. Again, it's gonna look cosmetically better when we're done regardless. Beautiful. Okay, cool. We'll take a tooth pickup times two and then a Bovie. Can I have a snap? Move the table up a little bit. Get the table up a scosche, one scoshe please. That's good and would you airplane toward my opponent? Thank you. That's great, thank you. I don't know if we're gonna need the, oh, the lap needle driver? Yeah, have it available. But don't open it, yeah. We found something exciting. Okay, fine. Get your thing then. Literally this is similar steps to taking down a stoma. Chronically inflamed. Yep. Again, I mean she was draining up until a few weeks ago, so that's good. Let's go this way now. Can we turn the suction off on the gastroscope for a few minutes? Thank you. Yeah, the hardest part about filming these cases is not having Katy Perry to help out. You know, I feel like I should have some headphones in just playing my own little, Katy Perry radio station. You just hear a little bit in the background and then like a... Can I get an Allis? Get another one, do two. Can I have a right angle? Fine. Yeah, remember the tract in your brain, it goes straight down but in reality it may track through the abdominal wall at a goofy angle. So let's keep that in mind, lemme take a tooth pickup for now. Okay, here's a little corner pocket here. Can I have a DeBakey? Nice, buzz those guys. Definitely a lot more scarring than you would expect for just a regular old G-tube. Again, I think the infection probably not super helpful for... Won't you take that guy there. I'll go here. And grab that skin edge there, we'll just try and find the regular tissue plane here between the stuff and the stuff. There we go. Yep. When it's open, it's sometimes easier. You can stick your finger or a probe or a Senn down in it and kind of follow that down. I think it goes that, I think that's stomach right there guys, I think that's stomach right there. So it may be a little, it kind of, it may go at a little bit of an upward angle. I don't think that's anything important or that the gastropexies did come through the abdominal wall here somewhere potentially as well. Depending if they did full-thickness gastropexies or not. Might be down to the level of the fascia here as well. It looks like we are. Yeah, she's pretty thin. She's thin. Yep. Get a DeBakey. Can I have a DeBakey? So I think this... Can I get an Army-Navy? Let's go to this location right here where we are. Go to the right lower quadrant of where we're working here and let's just try and identify some normal fascia. Okay, we can find some normal fascia there. That'll be a nice starting point for this to then work around the clock face and say, hey, this is also normal. There's normal fascia right there. There's fascia there so let's follow that edge around. Let's go this direction with it. Yep. Well okay, that's how we'll do it, you take those guys. I'll take the DeBakey. Let's come out of this corner here. Find the fascia. Goals in life. Goals in life on today's exciting edition of is that bowel? Our contestant is the stomach. Let's go back that way. Take it to the head. That's a fascial edge there. I don't think that any of this is real. I think that's the plane right there. I think this is just a layer of scum around. It's definitely not fascia. So I'm gonna try and give you that little window right there. Fine. Okay, let's keep going around the clock face. Take it down to the feet now. Yep, there we go. Let's go here, yep. That's a good pull Alicia, wonderful. There we go there. There's an edge right there. The last time I did one of these laparoscopically was on a lady that I had tried to close twice, endoscopically, and it didn't work both times. And when we took the specimen out, no joke, it looked like the world's tiniest stomach. It had a little esophagus and a little thing and a little corner. Like it just, it came out like the whole specimen looked like we had removed the world's tiniest foregut specimen. It looked just like the foregut. All right, that's fascia there. That's fascia, I think, yep. I think that's fascia, I think this is the edge right here. Yep, I think this is the edge of the stomach at the level of the fascia here. That's stomach there. That's abdominal wall fascia there. Now we're gonna have to open the fascia. We're gonna have a hole in the fascia when we do. The goal is to not make it gigantic but you know, some part of this needs to... It goes through the abdominal wall and it's embedded in the muscle. So we're gonna have to kind of take it out as - you know, with that in mind. So we'll try and find a little window here and we'll try and work our way through. That's fascia, good. There's stomach. We can also get a Kocher on the fascia. That's fascia in the clear. Let's lift that up and out and it's gonna let us work right here, okay? That's the bottom edge of the fascia there. So we can kind of grab from that spot then we can maybe even get another Kocher there. You free all of this stuff up. You've gotta make sure you've got it freed circumferentially and then you would take your stapler and fire it across here. You know the downside is you have a limited view of the inside world. You don't know exactly what stuck to what and it can be a challenge, but that's how the pediatric folks do it, right? That's how the ped surgeons do it. Aim toward her - retract, toward the tip of her instrument there. Yep, keep going, that's fine. Good. Okay. Stay on that jaw, there you go. Good, that's muscle. Yeah. So we are probably in the wrong plane in an okay way, in the intermuscular plane. This is going to be the posterior sheath then here stuck right there to it. Fine. There's some more muscle there. And buzz that rectus, good. This is gonna be the part that's obviously the most sticky 'cause muscle loves to stick to stuff when you expose it to organs. Bare muscle is very good at sticking to things unfortunately. It's a little more muscle. Okay. Is that skeletal muscle right there? It looks like rectus, doesn't it? Yeah, I think that's a little bit of rectus muscle stuck there to it. I don't think that's the specimen. Give it a little buzz and see if it jumps. Just buzz that like right there. Nope, not really. So maybe it is fistula tract. That's not though. That's stomach there - that's muscle, that's rectus there for sure. Coming this way, coming this way. We can always go back lap if we need to as well. Sometimes you push it back in and you invert it 'cause it's actually stuck to the abdominal wall still somewhere that you can't see from here. That's rectus muscle there. So that needs to come down and off of it. That's rectus there. Yep, I think so. On the bottom side, I definitely am. Wonderful. Let's go this way. From the darkness. That's rectus muscle there. All right. Come to papa moon. There's your staple line right there. Yep, you can see the end of it, this is abdominal wall fascia here. It's just stuck, it's the backside that's stuck still where there was still a little bit of gastropexy stuff. So stay there. That's skeletal muscle you're taking with you, you can see the staple line, right? There's the staple line right there. So we can see the entire staple line. This is gonna be some skeletal muscle that's stuck. Cici what happens if we leave some of the stomach in place? The fistula tract? Bad infection is possible? Yeah 'cause there's like epithelial tissue in here. Yeah? And so it's gonna make mucus and it's got bacteria in it. There's a little bit of abdominal wall. Stay on the down jaw, take a little bit of skeletal muscle there with you. Yep, that's great, do it. So yeah, you gotta make sure you get it all out. Now I mean it's not the end of the world if it happens, you would kind of dig here and pull it out. But also like, let's not do that. That's your specimen. Call it gastrocutaneous fistula tract. Okay, now let's do the following. Let's go back on the gas please. Gas on, high flow. It looks okay to me. You see posterior sheath, you can see the rectus abdominis and you can see my finger there. We should be able to close this open. I don't think we need to be laparoscopic to do it. Okay, so let's let the gas out then. Gas off. We're gonna take that number 1 PDS on a CT-1. I may do just a U-stitch, I mean a figure of eight. A little figure of eight that direction? Yeah, let's do it.

CHAPTER 11

Yep, this is on it. Get a nice bite there, we'll do it in four bites. I'll just put this under. Yep. Wonderful. So we'll close this with an absorbable suture. Hernias at G-tube sites are not common, but they are definitely reported and obviously this is no longer a G-tube site and we had to make the hole a bit bigger, so there's a one-centimeter hole here. If we put a one-centimeter trocar here laparoscopically, we would certainly close it up. And those are, you know, those are non-cutting trocars. We basically carved a big hole here so we're definitely gonna close it up, okay? There's your bite right there, Tori. Yep, there you go. Yep, take it. Hold on. Roll back a little bit. Get this to get that fat out, you don't need that. There you go, good. Okay. So checking to make sure there's nothing caught underneath. Let's put the gas back on. Home stretch, thank you.

CHAPTER 12

Looks okay to me. Come here. Let's look at the stomach one last time. Camera's been out. It's cold so it fogs up. It looks fine to me. That omentum's gonna all flop back up as soon as we're done, so, okay, fine. Let's get our ports out here.

CHAPTER 13

Looks good. We'll need some 4-0 Monocryl for the skin. I'll take the gas off please. Okay. Can you level the bed for us? So top, top and bottom, bottom. Tie the bottom two together. Air knot on my finger, put a bunch of them in and I'm gonna give you some back tension now so that it doesn't slide the wrong direction. All right, those guys will close the fascia. I'll keep the umbo stalk outta the way. So we'll close the rest of those with some 4-0 Monocryl and some Dermabond. Got a little bit of irritation there for us. We can just pour, whatever you got is fine. Yeah, yeah, don't open anything else. We're done, we'll take a dry gauze. Okay, so I say we put maybe - can I have two DeBakeys. So look, how about if we put like one deep dermal in the middle like that? Or even something in sort of Scarpa's layer there to there. And then one 3-0 in the deep dermis here to here. Or maybe two. So you'll put one deep here. And then one, two there. And you're gonna put three little wicks down in, we'll leave 'em in for 24-48 hours and she can just kind of unpack it and it'll be okay. Yeah? Okay. And then 4-0 for the rest, procedure is as billed. It's laparoscopic-assisted takedown of gastrocutaneous fistula and an upper endoscopy. And the specimen is gastrocutaneous fistula tract. There are not complications yet, and the wound class is clean contaminated. Okay. Nice job team. So Cici, did we have to do an endoscopy during the case? Did it do anything? It gave us I think assurance that we were in the right plane. But did we have to do that? I guess we didn't have to but I think it increased our ability to like accurately reset that portion of the stomach and reduce her risk of infections. So part of why I am a surgical endoscopist is because I believe that surgeons should have at a minimum the ability to do what we just did, which is to use an endoscopic view to guide a surgical intervention. This is a good example. We did not need to do any of that, but we looked to make sure there wasn't a foreign object there before we fired the stapler. Could the tack or the clip they'd tried to use to close it still be there? Sure. And if we had misfire the stapler, we would've said, oh, we should have, we should have looked, we were able to do a leak test and we had some assurances that it's not leaking. Do these leak commonly? They do not. The time to find a leak is today and now. Do staple lines bleed? Sure. Common? No. Was it bleeding? No. So now we know that the common things that you would be concerned about right now are not here. Doesn't mean they can't happen, but it does mean that we did absolutely our due diligence to make sure that there's not, you know, a problem that we could have managed, you know, here and now. It looked fine, you know, it wasn't actively leaking. The subcu stuff was a little sticky, but we didn't come across any pus and we're not closing it anyway. So I'm okay with just the doses that she got.

CHAPTER 14

So the procedure went more or less as we anticipated. She had some adhesions to the midline from her previous laparotomy that we could take down. There were some gastropexy sutures around the G-tube tract, which added a little bit of scarring. And as you saw from the video, we had some scissors that weren't working and that's just facts of life for surgery. Sometimes the tools and equipment you want aren't as readily available as you want. So you saw us switch out scissors there a few times. I think highlights for me would be the role of endoscopy here. You know, as a surgeon and a surgical endoscopist, I think it's very important that surgeons be comfortable using an endoscope to look around and diagnose problems and also to help guide their surgical interventions. And that's how we used it today. The patient's gonna stay overnight, we'll give her a liquid diet and then advance over the next couple of days to a more regular diet. And we left the wound packed open mostly because it's a fistula tract and there's some amount of contamination in that tract and I didn't wanna close the skin, so we left it packed and she'll just repack that at home. Some oral analgesics and then a follow up in about a month in clinic for further evaluation. During the procedure, you saw us have some issues with our insufflation and our insufflation pressure. There were times where our tank was not open and so we weren't getting gas. There were times where the tank was open and the gas was not turned on, so we had low pressure. And at one point during the case, my endoscopic carbon dioxide tank was empty and needed to be exchanged. Those are also issues that I think surgeons should be facile with. Not everybody in the operating room is good at laparoscopic surgery in terms of circulating nurses and assistant personnel. The team we're using today mostly does ear, nose, and throat surgery. And so they're not as used to using those tools and equipment as the rest of us are. And so part of the learning process, and part of why I was talking out loud with what those issues were, was to not only teach them what to do, but also for our students and for our residents there. I think you have to be good at troubleshooting those problems and understanding why is the alarm going off? Why is the gas low? Is the tank closed? Is the tank not open? Is the tubing disconnected? So you saw us sort of troubleshooting those during the procedure. I think those are very important things for general surgeons to be comfortable with doing on their own.