Feeding jejunostomy (Witzel)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• leak of feeds into the abdomen or around the tube
• tube blockage or falling out
• small bowel obstruction or twisting (volvulus) at the tube site
• wound or tube-site infection and skin irritation
• diarrhoea with tube feeds
• refeeding problems (low phosphate, potassium, magnesium) in a starved patient
• enterocutaneous fistula after the tube is removed
• rare bowel necrosis during feeding

Pre-operative details for this operation

1. Indicationwhy the stomach cannot be used (gastric outlet obstruction, oesophageal disease, aspiration risk) and expected duration of tube feeding
2. Nutritional assessmentweight loss over 6 months, BMI, serum albumin, SGA grade
3. Electrolytes and ECGsodium, potassium, magnesium, phosphate corrected before surgery
4. No contraindication to enteral feedingno distal obstruction, ileus, high-output fistula or shock
5. Previous abdominal surgery / scars
6. Done alone or with another operationAloneWith another operation (name)

Anaesthesia and position

1. AnaesthesiaGeneralLocal infiltration
2. PositionSupine

Operative findings

1. Duodenojejunal flexure (ligament of Treitz) identifiedYes
2. Jejunumcalibre, wall, any disease
3. Stomach / other organsfor example contracted scarred stomach, adhesions, peritoneal deposits

Procedure (steps)

1. Skin preparation and draping
2. IncisionUpper midline (about 5 cm above umbilicus)Left paramedianlength in cm
3. Transverse colon lifted, duodenojejunal flexure identified by sight and feel
4. Jejunal loop chosendistance from the duodenojejunal flexure in cm; reaches the abdominal wall without tension or kinking
5. Tube brought in through a separate stab in the left upper abdomenRed rubber catheterSilicone jejunostomy tubeInfant feeding tubesize in Fr; balloon catheters avoided or balloon disabled
6. Purse-string on antimesenteric bordermaterial and size (for example silk 3-0)
7. Enterotomy and tube passed distallylength of tube inside bowel in cm; intraluminal position confirmed by free flush and aspiration of saline or air
8. Witzel tunnelnumber of seromuscular Lembert sutures, tunnel length (about 2 to 3 cm), lumen not narrowed, tube not pierced
9. Jejunum fixed to the abdominal wallsutures around the tube exit and one extra suture distal to prevent twisting; length fixed
10. Patency and leak checksaline flushed after fixation
11. Omentum placed around the siteYesNot available

Closure, drains and dressing

1. Abdominal walllayers, suture material and technique
2. Skinmaterial
3. Tube fixation at skinsuture material; length of tube outside skin (cm)
4. Tube spigotted / flushedSpigotted after flush

Specimens and implants

1. SpecimensNoneBiopsy of any lesion seen (site)
2. Feeding tubetype, size (Fr), make, batch number; sticker pasted

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Vitals and abdomenpulse, BP, temperature; distension, pain
2. Start of feedswhen, type, rate and how it will be increased; slow start in a starved patient
3. Refeeding watchsodium, potassium, magnesium, phosphate and blood sugar daily for the first days of feeding
4. Flushingflush daily, before and after medicines and after stopping feeds
5. Feed intolerancereport nausea, bloating, pain or diarrhoea; stop feeds and inform surgeon if abdomen distends
6. Tube-site caredaily cleaning; check tube length outside skin each shift
7. IV fluids and analgesiatype, rate; drug and dose
8. Dietician reviewcalorie target and feed formula

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery