CASE 25

                         Final Surgery Operative Report
        31-67-68                            Request Number:  S991958
        Zach  Tabby  M                      Faculty Surgeon: Gregory, Clare
        FE-DOMESTIC MEDIUM HAIR  May99      Primary Surgeon: Dassler, Christopher
        Collins, Barbara & George           Student:         LEYBA
                                            Anesthetist:     HANSON
                                            
        Surgical    1) HERNIA - DIAPHRAGMATIC (2953)
        Procedures: 2) MISCELLANEOUS MATERIALS (1999); 8 Fr. trocar catheter
        Surgical Preparation     Hair Removal:   CLIPPER #40 BLADE
        of Patient               Scrub:          POVIDINE IODINE
                                 Final Solution: POVIDINE IODINE
                                 Antibiotics:    CEFAZOLIN


        Description of Surgical Procedure:

        Following induction of anesthesia, Zach was placed in dorsal recumbency, and the ventral abdomen, caudoventral thorax and medial thighs were clipped and
        aseptically prepared. The abdomen was then draped so as to create an approximately 25 X 5 cm fenestration over the ventral abdomen.
        Using a #10 scalpel blade, a ventral midline incision was made which extended from approximately the level of the xiphoid to the umbilicus. The ventral
        rectus fascia was cleared of overlying subcutaneous tissue and an incision through the linea alba was created to approximate the skin incision.
        Following retraction of the body wall from the incision site, an approximately 4-5cm dorsal-ventral rent was identified in the diaphragm. The liver (except
        for the right lateral lobe), gall bladder, stomach, and small intestine were found to have passed through the rent into the pericardium. All these organs
        were replaced to their normal anatomic position in the abdomen. Next, a 10 French thoracostomy tube was passed through the skin and body wall immediately
        lateral to the incision site, and the tip was then placed in the peritoneal space associated with the diaphragmatic defect. The defect was closed with 2-0
        Prolene in a simple continuous pattern. Following diaphragmatic repair an abdominal exploration was performed and no abnormalities were observed. The
        abdomen was then thoroughly lavaged with warmed normal saline. The chest tube was secured with a "Chinese finger trap" using 3-0 surgical nylon suture. The
        linea alba was then closed with 2-0 PDS suture in a simple continuous pattern. The subcutaneous tissue and dermal layers were closed together with 3-0
        Monocryl in a simple continuous pattern. The skin was apposed with skin staples.  The scrotum was plucked and a standard closed orchidectomy of the
        testes performed utilizing the technique of tying the spermatic cord and associated vasculature into a knot.  No complications were encountered.

The diaphragmatic hernia can be visualized below the center retractor with a lobe of liver within it.