Exploratory Laparotomy for Bowel Obstruction with Primary Repair of Two Diaphragmatic Hernias

CHAPTER 1

So my name is Kat Albutt. I'm one of the trauma surgeons here at Mass General. Earlier today, we had a patient who came into the emergency room who had a small bowel obstruction, but this small bowel obstruction was a little bit unique in that she had a transition point of her small bowel obstruction directly as her small intestine was entering a diaphragmatic hernia in her chest. She'd had a history of a Roux-en-Y gastric bypass as well as a paraesophageal hernia repair, and another diaphragmatic hernia repair that she couldn't tell us about, as well as several abdominoplasties. So we knew that this operation was gonna be slightly challenging, and that she had at least one hole in her diaphragm that we would need to fix. So, myself and one of the thoracic surgeons teamed up to do this case. The general steps of what we're going to do are to enter the abdomen safely, which in this case, with all of her prior abdominoplasties may actually be quite difficult. Get into the abdomen, lyse all of the adhesions in the abdomen, and then dissect the hernia sacs and the small bowel out of the hernia in the chest. Once we've been able to reduce the small bowel and large intestine back into the abdomen, our job will be to fix diaphragm, there are a couple ways we can do that. One is with mesh, one is with primary repair, we'll see when we're in the operating room. And then the next thing to do will be to check out all of the intestine, check out the anastomoses from the prior gastric bypass and make sure those are okay and then close up the abdomen. You'll see that this operation was a little bit different than what I described due to the complexity of her having had a prior repair of her diaphragm. So when we entered the abdomen, we saw that there were actually two hernias in the diaphragm, one of which was contained in small bowel, the other of which was contained in colon. We were able to free those both out of the chest. The colon dissection was a little bit more tedious. Once we were able to do that, we did a primary repair of the diaphragm with pledgeted sutures up to the anterior abdominal and chest wall and then ran the small intestine, the large intestine, and closed.

CHAPTER 2

Incision. This is gonna be a weird belly to get into. Just Bovie that. May I have a Schnidt please, Lauren. Right here. Can I have a Schnidt, please? All right, so that's definitely some structure. Hold up, this. Valery's on tonight. Grab a Schnidt. Can I have the Metzenbaum, please? Slow down as you're going through muscle stuff. Hold there... Metzenbaum, please. And now we're just trying to find the inside of the abdomen. All right, the abdominal cavity. Where it all begins.

CHAPTER 3

All right, can David have the abdominal wall? All right. So here is... Do you have suction? The hole... Now this is the bowel that was up there. It looks okay. There's the hole into the mediastinum. Yep. Yeah, I was expecting it to be more adhesed or something, but... Yeah, it's nice and anterior. I'll have to get a look at it, the rest of her diaphragm, to see if... Pull up. Our liver is fused over here. Come back. Do you want the bed up or you want? No, I just wanted to see above to see if I could see. Right here. Yeah, see look how small it is. Isn't that amazing? It's crazy. And the falc always gets pulled up into it. t's just, yeah - I mean it's like three, the size of three fingers. Yeah, it looks crazy on the scan. It's crazy. Yeah. So you might, could... We can get a bookie in if we think that's helpful. Do you want me to take down the falci? Yeah, so you wanna take - probably take down that falc and then reach up in there and see if you can grab all that preperitoneal fat and just pull it down because you're not gonna be able to see the hernia sac to reduce it, but you might just bluntly get it. Okay. Do you have another abdominal wall? Yeah, this far. See if we can see this. See if we can do this. Do you want a Rich to go with it? I'll take a Kelly. I can feel, I think her mesh from her... Do I feel mesh or do I feel? She had something. She had a paraesophageal hernia, yeah. The mesh you can see is way at the posterior hilum, so very posterior mediastinum. Shouldn't be able to see or feel that? But she had something else up there. Feel this. You hear it? What I'm popping on. It looked like little studs or tacks on CT scan. It feels like a tack of something. Somebody might have tried to fix this before. She said she did try to have it fixed with a Roux-en-Y reconstruction initially at the index case and then... But they said they did a paraesophageal hernia repair. I think they probably did both because there's definitely foreign body material in both spaces. Spaces, yeah. See if we can kind of... So I wonder if this is falci or not, you know? Yeah, it gets pretty drawn up in there. But I can't even see, like it's so fused, I can't even see over the liver. Do you have an empty ring clamp? Grab that, there's something. You have another ring clamp? That's the distal part of the sac. Got it. Cool. That looks like it's all the way sort of out and everted. And there is - is that still colon up there? It still colon? I don't know. Unlike a paraesophageal where you have to reduce the sac in order to get the contents down, you can reduce the contents here before you go to the sac, and satisfy yourself that the contents are down. No, there was colon up there. It was probably previously reduced. On the scan. But it feels like here. It's right here, and I don't know if it's that it reduced and I'm feeling it underneath, but I think there's colon in here. Sucker, please. Maybe not, we can just grab the transverse colon and see if it goes up. Respirator? Yeah, see this is the... Yes, there we go. That's what's stuck. He's strong, he's strong. Strong like man. No, but you can at least see and then... Okay, so this is more stuck than the small bowel was. Can you pull up more, Lauren, or no? Probably not. I'm already on my tip toes. So that's what, yeah, this is still colon up here. So can I open up the side here? Can I have the Bovie, please? Can we shift it to Hugh's side? Yeah. Thank you. Can I have the long tip on the Bovie? I don't want to devascularize this, pulling it down. David, can you see enough to Bovie? Yeah, stay high, right down on my fingertip. This did not just happen. The small bowel may have a acutely gone up there, but this colon has been here for a little while. So there's a stitch of some prior repair. Looks like an Ethibond. Yeah. David, get that. It's not very anastomosed because the defect is really here. But that's where the small bowel was. The small bowel was in this anterior one. And if you just feel it, you feel colon going way up there. There's definitely suture material as you said. Yeah. And her JJ is somewhere around here on the scan. I think it's the Roux limb that's actually, it was the Roux-en up in the chest, there's the JJ. Yeah, so the JJ was right anterior. It's the Roux limb that's up in the chest. So the Roux limb - this is probably the Roux limb, right? Yeah. So that should be going down. Sorry. Ask for your help, only to pin your glove. All right, so there's - you probably don't need any - you got no business up there, right? Take this apart from... There's no reason I can't go? Go ahead. The question is, is this - like, does this come around? It shouldn't be possible for her to have a Roux limb in her diaphragm because it's going posterior towards her... But I think this is - so here's her JJ, right? So. Yeah, so common channel is... So this is decompressed, right? So, that's probably common. This one is - that's going back to LOT. Yep. Do you agree? Yeah, I think so. Hook in there, David. So LOT. So BP, way down here. That's common channel. Yeah. And this is the Roux limb, which is... And this is what was stuck up there. Oh, so you're saying the Roux limb... Yeah, was stuck up, anteriorly. The distal end where her gastro-J is, should be away from any... Should be down, yeah. So that just leaves us with colon. And get this out. I had a pretty good grab around it. Take this. Yeah. It just looked very convincingly on the scan, though. Well, I think there's like so many people have fooled around here, right? Someone's fooled around by her stomach. Like this seems to me to be hernia sac and colon, right? Yeah. And then here's stitch. And then up here there's still - if I slide in above that, I can still feel colon in the chest. Like here. So this is all continuation. This is... That you just had your fingers in? Say what? You just pulled down some peritoneum, maybe the upper limits of the attachment. Yeah, my problem is if I stick my hands up here, put your fingers right above mine. There's still colon to go. Yeah. I mean, we can dissect some of this off, but... Or we can just say she's gonna get a... Where does the other end of the colon come from? Not a resection, but... All right, so here's a very poop filled colon and her... I think goes behind maybe. I don't know if she's got a retrocolic or an antecolic because she wasn't done here, but it certainly looks like it's retro. I mean like it's antecolic like the colon is... So that's colon, right, in grey? Yep. I think we should focus on... I guess the question is - where's her GJ? Oh, nice. There. Yep. Bovie. Bovie. It looks like that's maybe peritoneum invaginating now. This is what you drew out before? Not mine. Do you have a right angle? A lap. Can find where this... What you're doing is the right idea, just downward traction, and then we'll... It goes... Pull my phone outta my back pocket, and tell me who's calling me. Yeah, exactly, get that stuff. That's what's holding up there. See the colon, close? Yeah. Cheat up high. It's coming. Ever so slowly. Thought I could finally feel like I could feel the top of it. Let's see that right angle again? And this stuff can go. Do that with your finger. Okay, I think I'm like around the colon now. Yeah, you did it. All right, can I have a... That's sac coming with you? That's sac, yeah. I would like the Bovie just on my finger right here or actually, yeah, Bovie, what Hugh's got. You see this right here that you can see through? Yeah. Yep. Okay, do you have a Schnidt for me? Lauren, can you fix the lights, please? I feel like one is completely not in our field. Okay. Cheat high on all of these, David, because the colon's right there still. I just wanna see because there's part going and there's part coming, right? So this goes. I don't wanna go through her GJ. Go from down to up? - I think it's... The Roux limb was through a true defect, but it's the colons through a... Different. - Different. Separate defect. Yeah, I think she just blew out the whole left side, it was so tight. And I think it's hard because there's like some mesh in here. Yeah, there's some hernia sac, there's some mesh. And then to top it off, it's behind a Roux limb. Yeah, yeah. Really high. Yeah. Is it the colon? That's what we're working on right now. A bit of a small defect. Schnidt, you got it? Oh... Yeah, that's fine. Hugh missed - Hugh missed bypass surgery. So, he came back to join. I just love operating. The abdomen a day. I just don't wanna completely destroy the mesentery to the colon, you know. Hopefully you're not, hopefully that's all. There you go. Yep. This is, some of this might be mesentery of the Roux. All right, so here's our, I can now get behind. So here's our, so it's an antecolic anastomosis. And this comes right through here, all right. Yeah, this is where they repaired the trap. Yeah. This stuff. I think that's kind of... In the way? You can get it to drop down a little bit. Vessel here? No. Use your left hand. Burn yourself? So here's... Take that down from the tip. From the tip back. All right, so our GJ has to be somewhere up there. Yeah. Okay, and it's clearly in front of our colon, which I think is now down from the chest and comes from here around to here. Agree. So now the question is what else do we have to get down from inside there? And from where did this? There, can you feel the extent of the defect? Yeah, so there's that one anteriorly, and then, I can stick my entire fist through there. You feel that? We're gonna look at the colon, don't worry about it. It's hurting, but it doesn't mind. Take a Schnidt. The defect - if I spread my fingers out like that. I'll take a Schnidt, please. I got it. 3-0 tie, please. Do they not have free ties in thoracic surgery? Oh, Hugh only does robotic surgery. It's true. Dock the robot. Time for the robot now. I'd love to see where her liver is when she had the defect. Yeah, wouldn't it be great? It's completely fused from like trying to feel, but let's try and see. Like, can Lauren, can you shine the light in here? Yeah. No, I'm not trying to lift up ribs, but the deaver is actually a good idea. So here's liver. It's pretty fused up there, shine the light in. So yeah, what I would do now is try to take down the liver from part of the diaphragm get the bottom edge defect, control that. So, to move the liver over essentially? To get the liver to drop down. Right now it's probably stuck up to the underside of the diaphragm. Yeah, it is. By its triangular ligaments and by post-gastric bypass like everyone gets. Adhesions and... Get it to drop all the way down. Okay. Including by taking down the triangular ligament, then the diaphragm should come up and close it. I think it's honestly gonna be hard to work with a Bookwalter on this. Omni, maybe, but this is a lot like more force. Can I have a - the Bovie, please. That's what she would have done. She would put the upper hand in and sew the patient's costal arch to it. Really? Yeah. Giant number two Vicryls around the costal arch and then tie it to the upper end. It's my workout now. All right, so the question is here is where some of those mesh tackers are. I think I'm safe here. This is what they tried to do before. I'm like right on the edge of the mesh. Just pushed your bowel out of the way. No, like the big abdominal wall for this side. So I just feel the old mesh right here. Okay. There's no way that's a paraesophageal mesh. No. It's right there and I can actually see it. The tacks, huh?. I could actually see it for the first time just now. Good news is I don't think we need to do anything... That's what I was taking down, but... You feel it, it's like that rolled mesh anteriorly and tacks. Or sutures, whatever it is. Okay, that was a blow. Okay, now I see a lot more stuff that I recognize. Bovie. Like normal intra-abdominal stuff. And more liver. Yeah. All right, now we're getting somewhere. And there's this here, which can go. All right. So, all right. So, liver over here - is actually pretty free. Up here, it still needs to be taken down. My fingers all along here, suction. There's nothing there other than my finger behind that. Yeah, can I have the Bovie, please? Thank you. Oh, I feel this. I feel the whole mesh situation. And here's the other edge of the liver tented up here. You see it? So I think there's liver tented up right here. That looks adhesed to diaphragm. Do you want me to take it off the diaphragm? Yeah, what you'd like to see is just a hole. As much should be clear around it as possible. Lauren, can you suck in there? Okay, and the question is, can we get to the liver over here? Yeah. Yeah. I shoved my big dumb hand up there and just ripped a bunch of liver stuff down when you were gone. Oh, okay. All right, sounds great. Can we get the combat gloves, now? See how bad the damage is? Oh, damn. Reminder, don't step away from the table. Suction. I think your defect is... I think this is still... I think this needs to come down still. Yeah, a babcock. Can I have the Bovie for a second? Do you think this is diaphragm? Or is that? That is - no, I think that's old mesh. Because I feel the tacks right here. I'm almost behind them. One thing we don't wanna do is... Get up to the... Blowing up and we're disrupting the paraesophageal repair. Or the hepatic veins. We think about different things, Hugh. Yeah, because I think the defect, can I see the babcock, please. It's right here. That's diaphragm, right? Yep. So we can repair that. And the question I ask - what's up here? Does it matter? There's a big, I guess, no, that's above liver. Yeah, so that's above liver, so that's safe. Yeah. The question is, is there another hole anterior to that? I don't think so. If this is the bottom part of this defect, and we can get that to pop up to about here. Through it by pig sticking it. Yeah. Yeah, we'd need to - we're gonna come sort of transthoracic with the pig sticker, but otherwise we're not gonna able to put sutures down the other way. Does that make sense? Yes. Because if you feel it now you can feel, there's this small one here, and then there's the bigger one behind. Hey, guys, is that blood pressure real? I just flushed out, I think, yeah... No, it dropped. Thanks. I had just drawn a lab off. I'll send an ABG and let you know. Okay, thanks. No, thank you. It looks better. That's a lot better now, better... I like that number. You feel, it's like there's very little between them. There's one that comes up this way. And that's where the small bowel was in that anterior one. And then there's this other one, which is... This one, which goes this way. Yeah. Yeah. Yeah, slightly smaller than my fist, but... You think I could feel? The babcock's on the bottom edge of the defect. So this is the bottom edge. Do you feel it? You can feel like... So that's, I think you're feeling this one. There's one that goes straight in anteriorly, right under the costal margin. Right under the sternum towards over here. Stick your hands over mine. Yeah, I feel that one. That's where the small bowel was. The other one is different. There's another one that's down here. That one's bigger, much bigger. Yeah, and this one is much more... Yes. Do you have another ring forceps? You come towards me. Like this is also diaphragm. Yeah.

CHAPTER 4

So I'd make your stitches for this come inside to out, pledget, pledget. And then feed up. in And then we'll pig stick and grab both ends. So inside the hernia sac to like through and through the diaphragm this way? Yeah. Pledget, pledget. Yeah, from the chest to the abdomen. Yep. Through the pledget. Back out through the pledget. And then Abdomen through the chest. And then we'll pull up from inside. Do you want them on a pop, though? Yeah, on a pop. Okay. The longer ones, please. Active peristalsis, look at that. Very cute. Is there a side that you think you should start on? I usually try to go right in the middle for the first one and then just start bisecting. Okay, so is there a way with this we can tuck? The problem is she's really got no domain. Yeah, she's also a huge internal hernia risk. I dunno if the stuff that we did to get her colon down created another internal... Can you suck in there, Lauren? Yes. All right, this is diaphragm here. Hey. We have zero and CTX. Perfect. Great. All right, how many you said? Like 20. All right. Bye. You have an 11 blade? I will have an 11 blade. Do I currently? No. Lauren, can I have a lap that I'm gonna put... I got it. No, David, can you lift or... Okay, thanks. How's it going, Kat? It's going. So, two separate hernias. Yeah, so if you look here this, there's a hernia sac right here. I don't know if you can see. I can see, yeah. That goes over here. That was the small bowel, was stuck up in there. And then there's a much bigger defect down here, which when it's relaxed, can accommodate my entire fist first, and the colon was up there. So the bowel looked okay though? The bowel looks okay. I mean... That bowel look all decompressed. Yeah, we beat up the colon a little bit getting it out. So I'm gonna have to run that carefully, but... All right, enjoy. Challenging, but all done. Dave, why don't you take one of these, I'll take the other one. Can you hold this David? Pull like this. Out - yeah. That's a huge needle. Huge. Um-Hmm. All right, pledget please. Are you going to the other side of it? Yeah, she's gonna come back down through it. Oh, you wanna use the same one? Sorry, I thought you wanted to use two separate ones. I would've spaced it differently. And so this is now this way. So I need to be on your side, sucker please. No, I wanna pickup, thanks. All right, you have that 11 blade? And the pig sticker? Can we have pickups that work? Is that a possibility? Pickups that work? Yeah. Can I have a pair of Bonnies? You want another driver? Yeah. So where do we think that one's gonna wanna come to - here? You're right. Yeah, this side of the sternum and the other side. Do you wanna go around or? Pig sticker? All right, now lemme stab right here. Hold on. Where is this? Okay, I see you. Angle towards me a little bit. Perfect. Which is the left and which is the right? Doesn't matter. This is your left. This is the patient's left. All right, pickup, please. Open. Close. Needle. Got it? Yep, push out towards me. All right, yeah. Sucker. It looks like part of it got tacked up. The question is, I'm pretty convinced this is on your side, is on diaphragm. I'm not so convinced this is. Let's pull down. Where's our pledget? Should be... Yeah. So if you take your babcock off... That should close the defect mostly. Yeah, it does. Okay. There's like two or three finger breadths left this side and two left this side, which I think are actually the ones going up here. Okay. So I think the larger one to the left really just has like two or three finger breadths to go. Yeah, and if I drop it down, can you feel it? Yeah. It's huge. Yeah. Yep. Should probably put two more on this side and then... Oh, at least I think. Can I have that ring clamp, please? You want a babcock? I think the question is, there's a lot of redundant stuff here, but I think this is the actual diaphragm. Can we get the lights over here? All right, this is very clearly the diaphragm. Okay, I think I'm gonna drive one through here and then I'm gonna bisect on either side of it. Okay. If that makes sense. Yep. Okay, can we get the sucker in there Lauren, please? Yeah. You got it. Babcocks have a major design flaw, which is that they can be sutured into a wound while doing this. Ask me how I know that. Been there, done that. All right, can you take that off? Oh, okay, oh thank you. Make sure you don't pull through. That can go to David's side there. That's awesome. I'll take another needle driver, please. We'll cut the needle. 11 blade. So, you like about this far over? Yeah, I think there's gonna be one between these two, so maybe here. This is like essentially how you would do it laparoscopically too. Yeah. All right, hold on one second. Sucker, please. David, why don't you go around the other side and hold the deaver because I can't see anything without it. I don't see you yet. I think you're in. Okay. Do I have the... Stitch, please. Thank you. Needle off, please. Can we rotate the table towards Hugh, please? Let me know when. Thanks, all right, go ahead. Yep, you're good. Pickup. Sucker, please. To the right, lemme know when. So I'm holding the diaphragm and the babcock here and here you see my pledgets are underneath the diaphragm. So what I was doing was taking a stitch through the diaphragm that you see here, putting it on a pledget, coming back up through the diaphragm, which you see here. And then we're gonna adhere this piece of the diaphragm to the anterior abdominal wall or thoracic cavity depending on where you think we are. And then that space is gonna be obliterated. This is where the small bowel was, where my finger is, and the other one is where the colon was. So I think we need one more over here, maybe between these two and then I think that one will be done. Stitch, please. Thank you. And can we have another needle driver ready. And you're in between one and two there? Yep. And pick up a little bit there, David. Yep, pickup please, Lauren. Close. You got it. Yep, you're in. Close. Another snap. So if I take this one off, and I pull up on those, knowing where this cavity is... Just got liver, liver, liver going up. There's no more potential space, you wanna feel? Yeah, it's just what that should feel like. Just a bunch of bunched up crap and then like you try to really jam your fingers and get the suture, but... Right in there. Yeah. Nice and snug. Do you wanna do them as separate or? Probably can continue it as one row. Okay. I still, yeah because... I think I basically worked my way this way and hit the suture for that. From this one? Yeah. I would, why don't we do this, why don't we start closing it from this edge, and then we'll deal with the middle at the end and see if it looks better separate or together. Yep, sure. So I think it much higher here, right? Because it's very anterior. Yeah, this is the actual defect. What we don't have as quite as well on this side - can I have a dry lap, please. Don't have the bottom edge of it quite as well defined. Because it's not just that. I think it - I think it is though, because this right here is above - that's where the small bowel was, in this. Yeah, that's the defect. I'm just trying to figure out what's the bottom. Bottom edge of it. Yeah. Like where can we truly find diaphragm? Where do we put sutures down. And I guess, I just feel this flim-flam as the bottom edge here until like over here. That's right, that's right. Yeah. But I don't really feel like a... Do we have a small abdominal wall? Yeah. So if you put your - now, with this view... Sorry, I'll get my gloves. Really retracted? Yeah, it's just really retracted. Stuffing my fingers right there. Can I have a babcock? Way up here. We've got everything there. Yeah, like here, here, here sort of. Yeah, I can see this really well, right there. The defect is up underneath me. It's like even higher here. Okay. This is the... And you should be able to feel like the smooth underside of the sternum. So here's the hole, right? This is... So we've got this here, that's the problem in the middle, what do we have? I guess is the... - We're gonna have to go way back to get something. Because this can come over here, but this hole is really right here, right? Can I have the deaver instead? I felt like that pulled up pretty well. Suction. You sold me on separate defects, closing separate defects. Yeah. Basically go as far back as we could possibly go. Enough distance between these two stitches that there's good tissue in between them... All right, so we think this is gonna come up like here? Knife, please. I'm trying to get in between the ribs. Can you see me or no? Nope. I'm on bone. Just trust the system. It sounds like metal. I see the tip, but it's not all the way in. Advance maybe a centimeter - okay. Try to semi go through the same exact track. I feel the pledget under there nicely. Didn't do anything about - this one would be the lateral border. Yeah, and I think, yeah. And we need to get one like sort of up here almost. I feel like this one has to come right next to the sternum here. Yeah, same thing far back. Yep, and... Okay, you can put them in for bed, yep. Okay, see ya. Thanks, Dylan. Okay, can you get the... Yeah. Is that better? Say what? Okay. I have it? Yep. That's pretty good, the only area where there's... Can you pull up on, can I have a snap on this side, please? So if I pull up on this side and you pull up on that side, is there still a little defect right in the middle? Yeah, definitely. Right here, yeah. So, I can feel diaphragm there between my fingers. Can I have the ring forceps, please? You pick up the skin. I don't know if this is just hernia sac or what? That's lower than our previous sutures. Well, I think there are two different levels, this one and that one, right? Can I have the deaver? I think that one goes to this side of the sternum or across to this side. Still right here, a finger, I can get through between these two. I think this side is done. You feel it? We pull up on this one, do you still have it? Can you reach your finger up and find this suture? Yeah, I can... Can - yeah. I'm pulling on one of yours, I think. It's this one, maybe? I mean, the other option is, if there's nothing to really go through there, you can just pig stick through, pass it through the pledget. That's much more what you do with laparoscopy. Just kind of hold the diaphragm up and the pig sticker goes all the way. Yeah. I think, let's try to tie these and see... These are zeros, right? I'm not gonna break them? They're zeros. Thanks for coming to help. Love a good giant hernia. Plus, secret Roux-en-Y bypass that you didn't know about. That was a little bit of bait and switch, Kat. I know you. So just feel right here. Like I could force my finger into it if I really tried. Yeah. But I also think that the liver's gonna be there. Yeah, I think I'm not that worried about that. Even if I get my finger up there, it doesn't really go anywhere. This one closed up real nice. This one on this side, yeah. I think we're pretty good. All right. Do you wanna do anything intentionally or just see how she does? I mean, obviously we'll get a chest x-ray, but... Yeah. Just sit tight? Okay.

CHAPTER 5

All right, let's go find this colon. Two 0 looped PDS. I don't think that's true. They gave me a number one loop the other day. This was clearly where it transitioned, you see? Yeah. So this is where it went from normal colon to colon stuck again. And then that comes over here. Thanks, thanks Hugh, really appreciate it. And then that comes over here. The colon all looks okay. The question is what mesenteric traps did we create? Bovie, please. Whoa, can I have some light? Not all the way, we've had prior biliary colic, yeah. See the vein? Yeah. Come through here. Pickup, please. Okay, can we have a bunch of irrigation, please? She may be a double. Yeah. I need some more irrigation.

CHAPTER 6

Can I have two Kochers? How extra nice of you. I don't really know what to grab. Grab that peritoneum, another Kocher, please. Can I have one more Kocher? Okay, get this stuff too. Can I have the Bovie, please? All right. I assume you're actually gonna sew her abdomen closed? No, she is most definitely getting staples. Yes. Staples actually, depending on whose data you believe, have better cosmetic outcomes a lot of times than... Isn't it all contingent on whether you take them out on time? Yeah. I think that is at least in part true. But presumably, someone tried it once. This is a very stubby needle driver, Lauren. I kinda like it. What do you mean by stubby? It's like a short stubby needle driver. At least the scar feels like it's got some oomph to it. Okay, we'll have the second loop. Straight up towards me. Yep. Yeah, I'm sure it's stripped down. Say what? Hold on, just we're gonna pull it through and then we'll loop. Take this stuff as well as the peritoneum all the way through. Try not to get as close to the skin. Yeah. Get that peritoneum that's folded down there. Thank you. Yep. Just push it through, get your - yep.

CHAPTER 7

What we actually did in this case that was a little bit unique is, she actually had two defects in her diaphragm. A more anterior defect on the left hand side that was containing small bowel, and a bigger defect on the right hand side that was containing her colon. The small bowel reduced very, very easily. Like I was just able to pull it out of the chest the moment we got into the abdomen. But the colonic dissection out of the hernia sac was much more difficult. There was old hernia mesh there from one of her prior repairs, whether it was her paraesophageal or another attempt at repairing this hernia. And so it took us a while to dissect the colon out of the chest. Once we were able to safely do that, then it came to fixing the diaphragmatic hernia and figuring out how we were gonna do that. Ultimately, what we chose to do was a primary repair by pledgeting her diaphragm up to the anterior abdominal wall. To do that, we had to take down the liver and to really isolate the diaphragm. And then using 0 Ethibond sutures, we were able to do a pledgeted repair of the diaphragm up to the abdominal wall and the chest wall so that there would be no further holes. We then ran the entire small bowel, and the colon that we dissected free looked okay as well as the small bowel and the anastomoses from her Roux-en-Y. So then we closed.