Operative report Bariatic Surgery

Operative report 1

Preoperative Diagnosis

Morbid obesity (BMI 44.8 kg/m²) refractory to conservative weight loss measures.

Postoperative Diagnosis

Same.

Procedure Performed

Laparoscopic sleeve gastrectomy.

Indication

The patient is a morbidly obese adult with a BMI of 44.8 kg/m² and obesity-related comorbidities, including hypertension and obstructive sleep apnea. The patient has failed prolonged attempts at weight reduction through supervised dietary modification, exercise, and medical management. Following multidisciplinary bariatric evaluation, the patient was deemed an appropriate candidate for laparoscopic sleeve gastrectomy. The risks, benefits, alternatives, including bleeding, infection, leak, stricture, injury to adjacent organs, venous thromboembolism, and death were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced. Sequential compression devices were applied for deep venous thrombosis prophylaxis, and preoperative intravenous antibiotics were administered. The abdomen was prepped and draped in the usual sterile sterile fashion. A surgical time-out was performed.

Pneumoperitoneum was established using a Veress needle technique, and the abdomen was insufflated with carbon dioxide to 15 mmHg. A 12-mm optical trocar was inserted above the umbilicus under direct visualization, followed by placement of additional laparoscopic working ports in the left upper quadrant, right upper quadrant, and epigastrium. A Nathanson liver retractor was placed to elevate the left lobe of the liver, providing excellent exposure of the proximal stomach and gastroesophageal junction.

Inspection of the abdominal cavity revealed no unexpected pathology.

The greater curvature of the stomach was mobilized beginning approximately **5 cm proximal to the pylorus**. The gastrocolic ligament was divided using an advanced bipolar energy device, entering the lesser sac. The dissection was continued proximally with division of the short gastric vessels and posterior gastric attachments up to the angle of His. The left crus of the diaphragm was identified, and the gastric fundus was completely mobilized to ensure complete fundal resection.

A 40-French bougie was advanced by the anesthesia provider along the lesser curvature into the pylorus to serve as a sizing guide.

Sleeve gastrectomy was performed using sequential laparoscopic linear stapler firings beginning approximately 5 cm from the pylorus and continuing alongside the bougie toward the angle of His. Appropriate staple cartridge selection was utilized based on gastric wall thickness, with staple line reinforcement employed throughout the gastric transection. Care was taken to avoid narrowing at the incisura angularis and to preserve an adequate distance from the gastroesophageal junction.

Following completion of the gastric transection, the staple line was carefully inspected and found to be hemostatic. The resected stomach was placed into an endoscopic specimen retrieval bag and removed through the enlarged 12-mm trocar site.

An intraoperative leak test was then performed by occluding the pylorus while insufflating air through an orogastric tube with the staple line submerged beneath sterile saline. No air bubbles or evidence of staple line leak was identified.

The staple line was again inspected, and no bleeding or injury was noted. The abdominal cavity was irrigated and suctioned clear. Pneumoperitoneum was released. All trocars were removed under direct visualization. The fascial defect at the 12-mm port site was closed with absorbable suture, and the skin incisions were closed with subcuticular absorbable sutures followed by sterile dressings.

The patient tolerated the procedure well, was extubated in the operating room, and transferred to the recovery area in stable condition.

Findings

* Morbid obesity.

* Normal upper abdominal anatomy.

* Complete mobilization of the gastric fundus.

* Successful laparoscopic sleeve gastrectomy over a 40-French bougie.

* Negative intraoperative leak test.

* Excellent staple-line hemostasis.

Specimen

Sleeve gastrectomy specimen (portion of stomach) sent for permanent pathology.

Implants

None.

Check your answer

43775 – Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy).

Operative report 2

Preoperative Diagnosis

1. Morbid obesity (BMI 46.2 kg/m²).

2. Symptomatic gastroesophageal reflux disease.

3. Hiatal hernia.

Postoperative Diagnosis

Same.

Procedure Performed

1. Laparoscopic sleeve gastrectomy.

2. Laparoscopic hiatal hernia repair.

Indication

The patient is a morbidly obese adult with a BMI of 46.2 kg/m² and obesity-related comorbidities, including hypertension, obstructive sleep apnea, and chronic gastroesophageal reflux disease. Preoperative upper gastrointestinal imaging and endoscopy demonstrated a moderate sliding hiatal hernia. Following multidisciplinary bariatric evaluation, the patient was deemed an appropriate candidate for laparoscopic sleeve gastrectomy with concurrent hiatal hernia repair. The risks, benefits, and alternatives were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced. Sequential compression devices were applied, and prophylactic intravenous antibiotics were administered. The abdomen was prepped and draped in the usual sterile fashion. A surgical time-out was performed.

Pneumoperitoneum was established using a Veress needle, and the abdomen was insufflated to 15 mmHg. A 12-mm optical trocar was inserted above the umbilicus, followed by placement of additional laparoscopic working ports in the right upper quadrant, left upper quadrant, and epigastrium. A Nathanson liver retractor was positioned to elevate the left lobe of the liver, providing excellent exposure of the esophageal hiatus and proximal stomach.

Inspection of the upper abdomen demonstrated a **moderate sliding hiatal hernia**, with the gastroesophageal junction displaced above the diaphragmatic hiatus.

Hiatal Hernia Repair

The pars flaccida was divided, exposing the right crus of the diaphragm. The phrenoesophageal membrane was carefully divided, and circumferential mediastinal dissection of the distal esophagus was performed. The hernia sac was completely reduced into the abdominal cavity and dissected free from the mediastinum. Approximately **3 to 4 cm of tension-free intra-abdominal esophagus** was obtained.

The right and left diaphragmatic crura were identified and approximated posterior to the esophagus using **three interrupted nonabsorbable 0 Ethibond sutures**, resulting in a tension-free posterior cruroplasty. The repair was inspected and found to be secure without narrowing of the esophagus.

Sleeve Gastrectomy

Attention was then directed to the sleeve gastrectomy. The greater curvature of the stomach was mobilized beginning approximately 5 cm proximal to the pylorus. The gastrocolic ligament was divided using an advanced bipolar energy device, entering the lesser sac. The short gastric vessels and posterior gastric attachments were completely divided to the angle of His, ensuring complete mobilization of the gastric fundus.

A 40-French bougie was advanced by the anesthesia provider along the lesser curvature into the pylorus to calibrate the sleeve.

Sequential firings of a laparoscopic linear stapler were performed beginning approximately 5 cm proximal to the pylorus and continuing alongside the bougie toward the angle of His. Appropriate staple cartridge loads were selected according to gastric wall thickness. Staple-line reinforcement was utilized throughout the gastric transection. Particular attention was paid to avoiding narrowing at the incisura angularis and preserving an adequate distance from the gastroesophageal junction.

The resected stomach was placed into an endoscopic retrieval bag and removed through the enlarged trocar site.

An intraoperative leak test was performed by insufflating air through an orogastric tube while the staple line was submerged under saline. No air leak was identified.

The staple line demonstrated excellent hemostasis without evidence of bleeding. The hiatal repair remained intact without tension.

The abdominal cavity was irrigated and suctioned dry. All instruments and trocars were removed under direct visualization. The fascial defect at the 12-mm trocar site was closed with absorbable suture. Skin incisions were closed using subcuticular absorbable sutures followed by sterile dressings.

The patient tolerated the procedure well, was extubated in the operating room, and transferred to the recovery area in stable condition.

Findings

* Morbid obesity.

* Moderate sliding hiatal hernia.

* Successful laparoscopic reduction of the hiatal hernia with posterior cruroplasty.

* Successful laparoscopic sleeve gastrectomy performed over a 40-French bougie.

* Negative intraoperative leak test.

* Excellent staple-line hemostasis.

Specimen

Sleeve gastrectomy specimen (portion of stomach) submitted for permanent pathological examination.

Implants

None.

Check your answer

Operative report 3

Preoperative Diagnosis

1. Morbid obesity (BMI 45.6 kg/m²).

2. Extensive intra-abdominal adhesions secondary to prior abdominal surgery.

Postoperative Diagnosis

Same.

Procedure Performed

1. Laparoscopic sleeve gastrectomy.

2. Laparoscopic lysis of adhesions.

Indication

The patient is a morbidly obese adult with a BMI of 45.6 kg/m² and obesity-related comorbidities including hypertension and obstructive sleep apnea. The patient has failed conservative weight-loss measures and was evaluated by the multidisciplinary bariatric surgery team. The patient also has a history of prior upper abdominal surgery, placing the patient at increased risk for significant intra-abdominal adhesions. The risks, benefits, and alternatives were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced. Sequential compression devices were applied, and prophylactic intravenous antibiotics were administered. The abdomen was prepped and draped in the usual sterile fashion. A surgical time-out was performed.

Pneumoperitoneum was established using a Veress needle at Palmer's point because of the patient's previous abdominal surgery. The abdomen was insufflated to 15 mmHg, and a 12-mm optical trocar was inserted under direct visualization. Additional laparoscopic working ports were placed in the left upper quadrant, right upper quadrant, and epigastrium. A Nathanson liver retractor was inserted to elevate the left lobe of the liver.

Lysis of Adhesions

Initial inspection revealed **dense omental and small bowel adhesions involving the anterior abdominal wall, left upper quadrant, and greater curvature of the stomach**, significantly limiting visualization and preventing safe placement of the remaining trocars and exposure of the operative field.

Extensive laparoscopic adhesiolysis was therefore performed using sharp dissection, laparoscopic scissors, and an advanced bipolar energy device. Dense fibrous adhesions between the omentum and anterior abdominal wall were divided. Additional adhesions tethering the greater curvature of the stomach and proximal gastric fundus were carefully lysed while preserving the stomach, transverse colon, spleen, and adjacent small bowel. Careful traction-countertraction technique was utilized throughout the dissection.

The adhesiolysis required approximately **35 minutes**, substantially increasing the complexity and operative time before the planned bariatric procedure could safely proceed. Following complete adhesiolysis, normal upper abdominal anatomy was restored, allowing adequate exposure of the stomach and hiatus.

Sleeve Gastrectomy

The greater curvature of the stomach was mobilized beginning approximately **5 cm proximal to the pylorus**. The gastrocolic ligament was divided using an advanced bipolar energy device, entering the lesser sac. The short gastric vessels and posterior gastric attachments were divided completely to the angle of His, allowing complete mobilization of the gastric fundus.

A **40-French bougie** was advanced by the anesthesia provider along the lesser curvature into the pylorus to calibrate the gastric sleeve.

Sequential firings of a laparoscopic linear stapler were performed beginning approximately **5 cm proximal to the pylorus** and continuing alongside the bougie toward the angle of His. Appropriate staple cartridge loads were selected according to gastric wall thickness. Staple-line reinforcement was utilized throughout the gastric transection. Particular attention was paid to avoiding narrowing at the incisura angularis and preserving an adequate distance from the gastroesophageal junction.

The resected stomach was placed into an endoscopic specimen retrieval bag and removed through the enlarged 12-mm trocar site.

An intraoperative leak test was performed by insufflating air through an orogastric tube while the staple line was submerged beneath sterile saline. **No air leak was identified.**

The staple line was carefully inspected and demonstrated excellent hemostasis. The previously lysed adhesion sites were re-examined and showed no evidence of bleeding or bowel injury.

The abdomen was irrigated and suctioned dry. All trocars were removed under direct visualization. The fascial defect at the 12-mm trocar site was closed with absorbable suture. Skin incisions were closed with subcuticular absorbable sutures followed by sterile dressings.

The patient tolerated the procedure well, was extubated in the operating room, and transferred to the recovery area in stable condition.

Findings

* Morbid obesity.

* Dense intra-abdominal adhesions involving the anterior abdominal wall, greater omentum, left upper quadrant, and greater curvature of the stomach secondary to prior abdominal surgery.

* Extensive adhesiolysis required before safe exposure of the stomach.

* Successful laparoscopic sleeve gastrectomy performed over a 40-French bougie.

* Negative intraoperative leak test.

* Excellent staple-line hemostasis.

Specimen

Sleeve gastrectomy specimen (portion of stomach) submitted for permanent pathological examination.

Implants

None.

Check your answer

43775 – Laparoscopic sleeve gastrectomy.

Coding Note : The lysis of adhesions is not automatically separately reportable. It may be separately reportable only if it is extensive, medically necessary, performed to treat pathologic adhesions rather than simply gain routine exposure, and significantly exceeds the work normally required for sleeve gastrectomy

Operative report 4

Preoperative Diagnosis

1. Morbid obesity (BMI 47.3 kg/m²).

2. Type 2 diabetes mellitus.

3. Hypertension.

4. Obstructive sleep apnea.

Postoperative Diagnosis

Same.

Procedure Performed

Laparoscopic Roux-en-Y gastric bypass with Roux limb measuring **150 cm**.

Indication

The patient is a morbidly obese adult with a BMI of 47.3 kg/m² and obesity-related comorbidities including type 2 diabetes mellitus, hypertension, and obstructive sleep apnea. The patient has failed multiple supervised attempts at weight reduction through diet, exercise, and medical management. Following multidisciplinary bariatric evaluation, the patient was determined to be an appropriate candidate for laparoscopic Roux-en-Y gastric bypass. The risks, benefits, alternatives, including bleeding, leak, anastomotic stricture, bowel obstruction, internal hernia, nutritional deficiencies, venous thromboembolism, and death were discussed. Informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced. Sequential compression devices were applied, and prophylactic intravenous antibiotics were administered. The abdomen was prepped and draped in the usual sterile fashion. A surgical time-out was performed.

Pneumoperitoneum was established using a Veress needle, and the abdomen was insufflated with carbon dioxide to a pressure of 15 mmHg. A 12-mm optical trocar was inserted supraumbilically under direct visualization. Additional laparoscopic working trocars were placed in the right upper quadrant, left upper quadrant, and epigastrium. A Nathanson liver retractor was positioned to elevate the left lobe of the liver.

Inspection of the abdomen revealed no unexpected pathology.

Creation of Gastric Pouch

The lesser omentum was opened adjacent to the lesser curvature. A window was created posterior to the stomach. Using sequential firings of a laparoscopic linear stapler, a **30-mL proximal gastric pouch** was created just distal to the gastroesophageal junction. The gastric pouch was completely separated from the excluded stomach and inspected for hemostasis.

Creation of Roux Limb

The ligament of Treitz was identified. The proximal jejunum was measured approximately **50 cm distal to the ligament of Treitz**, where the jejunum was divided using a laparoscopic linear stapler.

The distal jejunal segment was measured **150 cm** to create the Roux limb. The Roux limb was brought to the upper abdomen in an antecolic, antegastric fashion without tension or twisting.

Jejunojejunostomy

A side-to-side stapled jejunojejunostomy was created between the biliopancreatic limb and the Roux limb using a laparoscopic linear stapler. The common enterotomy was closed in two layers using absorbable running suture. The anastomosis was inspected and demonstrated excellent perfusion without bleeding.

Gastrojejunostomy

An anterior gastrotomy was made in the gastric pouch and a corresponding enterotomy was created in the Roux limb. A stapled gastrojejunostomy was fashioned using a linear stapler. The common enterotomy was closed with a running absorbable suture reinforced with interrupted seromuscular sutures. The anastomosis was widely patent without tension.

An orogastric tube was advanced into the gastric pouch. The gastrojejunostomy was submerged beneath sterile saline while air was insufflated through the tube. **No air leak was identified.**

Closure of Mesenteric Defects

The **jejunojejunostomy mesenteric defect** was closed using interrupted nonabsorbable sutures.The **Petersen's defect** between the Roux mesentery and transverse mesocolon was also closed with interrupted nonabsorbable sutures to reduce the risk of future internal hernia.

Both closures were inspected and found to be complete without narrowing of the bowel.

The abdominal cavity was irrigated and suctioned dry. Excellent hemostasis was confirmed throughout the operative field.

The excluded stomach, Roux limb, biliopancreatic limb, and jejunojejunostomy were inspected and demonstrated excellent perfusion without evidence of ischemia or tension.

Pneumoperitoneum was released. All trocars were removed under direct visualization. The fascial defect at the 12-mm trocar site was closed with absorbable suture. Skin incisions were closed with subcuticular absorbable sutures followed by sterile dressings.

The patient tolerated the procedure well, was extubated in the operating room, and transferred to the recovery area in stable condition.

Findings

* Morbid obesity.

* Normal upper abdominal anatomy.

* Successful creation of a 30-mL gastric pouch.

* Roux limb measured **150 cm**.

* Tension-free gastrojejunostomy and jejunojejunostomy.

* Negative intraoperative leak test.

* Petersen's defect and jejunojejunostomy mesenteric defect closed.

* Excellent hemostasis throughout the procedure.

Specimen

None.

Implants

None.

Check your answer

43644 – Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (Roux limb 150 cm or less).

Operative report 5

Preoperative Diagnosis

1. Morbid obesity (BMI 42.8 kg/m²).

2. Hypertension.

3. Obstructive sleep apnea.

Postoperative Diagnosis

Same.

Procedure Performed

Laparoscopic placement of an adjustable gastric restrictive device (adjustable gastric band) with subcutaneous access port.

Indication

The patient is a morbidly obese adult with a BMI of 42.8 kg/m² and obesity-related comorbidities including hypertension and obstructive sleep apnea. The patient has failed prolonged supervised attempts at weight reduction through dietary modification, exercise, behavioral therapy, and medical management. Following multidisciplinary bariatric evaluation, the patient was deemed an appropriate candidate for laparoscopic adjustable gastric band placement. The risks, benefits, and alternatives, including bleeding, infection, gastric perforation, band slippage, pouch dilation, port complications, erosion, dysphagia, and the potential need for revision or removal, were discussed. Informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced. Sequential compression devices were applied, and prophylactic intravenous antibiotics were administered. The abdomen was prepped and draped in the usual sterile fashion. A surgical time-out was performed.

Pneumoperitoneum was established using a Veress needle, and the abdomen was insufflated with carbon dioxide to a pressure of 15 mmHg. A 12-mm optical trocar was inserted supraumbilically under direct visualization. Additional 5-mm laparoscopic working ports were placed in the right upper quadrant, left upper quadrant, and epigastrium. A Nathanson liver retractor was inserted to elevate the left lobe of the liver, providing excellent exposure of the gastroesophageal junction.

Diagnostic laparoscopy demonstrated normal upper abdominal anatomy without evidence of hiatal hernia or other pathology.

The pars flaccida was opened using an energy device to expose the right crus of the diaphragm. Careful dissection was performed posterior to the gastroesophageal junction, creating a retrogastric tunnel immediately adjacent to the angle of His while preserving the vagus nerves and surrounding structures.

An **adjustable gastric band** was introduced into the abdomen through the 12-mm trocar and advanced through the retrogastric tunnel. The band was positioned around the proximal stomach approximately **2 cm below the gastroesophageal junction** and secured in its locked position without tension.

Anterior gastro-gastric fixation was then performed using **three interrupted nonabsorbable seromuscular sutures** between the gastric fundus and proximal stomach to imbricate the stomach over the band and minimize the risk of band slippage.

The connecting tubing was brought through the abdominal wall via the left upper quadrant port site.

A small subcutaneous pocket was created over the left upper quadrant abdominal wall. The **subcutaneous access port** was connected to the tubing, secured to the anterior rectus fascia with interrupted nonabsorbable sutures, and confirmed to be stable without rotation.

The band system was accessed using the manufacturer's access needle. Appropriate saline was instilled to verify patency of the tubing and port system, after which the band was left essentially unfilled according to standard postoperative protocol.

The tubing was positioned without kinking or tension. The band, tubing, and access port were inspected and found to be in excellent position.

The abdomen was irrigated and suctioned. Hemostasis was confirmed throughout the operative field.

Pneumoperitoneum was released. All trocars were removed under direct visualization. The fascial defect at the 12-mm trocar site was closed using absorbable suture. Skin incisions were closed with subcuticular absorbable sutures followed by sterile dressings.

Instrument, sponge, and needle counts were correct at the completion of the procedure.

The patient tolerated the procedure well, was extubated in the operating room, and transferred to the recovery area in stable condition.

Findings

* Morbid obesity.

* Normal upper abdominal anatomy.

* No hiatal hernia identified.

* Successful laparoscopic placement of an adjustable gastric band.

* Secure anterior gastro-gastric fixation performed.

* Subcutaneous access port securely implanted and functioning appropriately.

* Excellent hemostasis without intraoperative complications.

Implants

* Adjustable gastric band system with connecting tubing.

* Subcutaneous access port.

Check your answer

43770 – Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components).