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Gastric Perforation Associated with Bilateral Inguinal Hernias
e12
Spectacular Cases
ongoing retroperitoneal hemorrhage followed by right nephrectomy for hilum injury. The remaining missile tract through psoas muscle was hemostatic. A right thoracotomy was performed for ongoing hemorrhage from the right chest tube. Wedge resections of the upper and lower lobes and a formal middle lobectomy were completed. Vascular surgery identified a brachial artery injury near the bifurcation and performed a repair with ipsilateral basilic vein. On postoperative day 2, after resuscitation led by critical care intensivists, the patient was stable for completion right hemicolectomy, ileocolic anastomosis, cholecystectomy secondary to missile tract proximity, removal of balloon tamponade and abdominal closure. The course was complicated by left forearm compartment syndrome on postoperative day 2, requiring emergent volar and dorsal forearm fasciotomy and subsequent skin grafting by hand surgery. The patient was discharged home 4 weeks after admission with moderate sensory and motor deficits of his left hand. The patient survived these critical injuries through effective communication and collaboration among the involved disciplines. Damage Control Surgery: Not Just for Trauma Ornela A Dervishaj, MD, PGY3 Brooklyn Hospital Center, a Mount Sinai Medical Center Affiliate, Brooklyn, NY A 64-year-old male patient, 12 days after a hand-assisted laparoscopic right hemicolectomy for an ileocolic mass, presented to the emergency department in acute respiratory distress and altered mental status. After rapid sequence intubation, a surgical consult was obtained for abdominal distention. Initial evaluation revealed an overweight, soft abdomen with mild distention, and well-healing surgical scars. Labs revealed acute kidney injury with a creatinine of 7.5 mg/dL, and white blood cell count of 16.8. After initial resuscitation, a CT scan of the head, chest, abdomen, and pelvis was performed, and was significant for a left-lower-lobe infiltrate with pleural effusion and fluid in the right-lower quadrant of the abdomen, likely postoperative in nature. Empiric antibiotics were started for presumed pneumonia and patient was upgraded to the ICU. Sixteen hours after admission, the patient was noted to have worsening abdominal distention with feculent drainage from the incision and bladder pressure of 34 mmHg, confirming abdominal compartment syndrome. He was taken to the operating room and found to have feculent peritonitis secondary to a through-andthrough enterotomy in the jejunum and complete dehiscence of the ileocolic anastomosis. During the procedure the patient went into asystole, Advanced Cardiac Life Support protocol was initiated with return of spontaneous circulation in 10 minutes. This prompted a damage control approach at this initial surgery, where the enterotomies were closed using a GIA stapler (Covidien) and the abdomen remained open using a negative pressure system. The patient was brought back to the SICU and after further resuscitation and hemodialysis, returned to the operating room on postoperative day 2. No further injuries were identified, the jejunum was re-anastomosed, and an ileostomy was created. The patient endured a complicated postoperative course with septic shock, hypoxic brain injury, myocardial infarction, acute kidney injury, acute respiratory
J Am Coll Surg
distress syndrome, and developed multiple intra-abdominal collections. Despite this, the patient eventually recovered, was extubated on postoperative day 13, recovered full kidney and neurologic function and was discharged on postoperative day 32. Damage control surgery can be lifesaving in multiple organ failure due to an acute abdomen. Gastric Perforation Associated with Bilateral Inguinal Hernias Evan Fitz, MD General Surgery Resident, PGY3, Ray Chihara, MD, PhD General Surgery Resident, PGY8, Katie Jo Stanton-Maxey, MD Assistant Professor of Surgery Department of Surgery, Indiana University School of Medicine, Indianapolis, IN A 49-year-old male patient presented by ambulance to the county safety-net hospital complaining of severe abdominal pain after eating dinner. He was evaluated by the emergency department and found to have a rigid abdomen and enormously distended scrotum consistent with bilateral inguinal hernias, which he reported had been present for 10 years (Figure 1). The General Surgery team was urgently consulted for evaluation. He was significantly tachycardic and soon became unresponsive. He was intubated, and nasogastric tube placement returned several liters of enteric contents. Aggressive fluid resuscitation was initiated. Plain film radiography was obtained, revealing pneumoperitoneum and nearly the entire gastrointestinal tract except for a portion of the stomach contained within the scrotum (Figures 2 and 3). He was taken emergently to the operating room, where laparotomy was performed. The distal stomach, duodenum, as well as the head of the pancreas, were reduced from the right inguinal hernia. Nearly the entire small bowel and colon were reduced from the left inguinal hernia. The entire bowel was determined to be viable. There was massive contamination of the right paracolic gutter, secondary to an 11-cm perforation located on the lesser curvature of the stomach (Figure 4). This was repaired primarily. Due to the chronic nature of the hernias, there was a substantial loss of domain which prohibited abdominal closure. The large bilateral inguinal
Figure 1.
Vol. 222, No. 2, February 2016
Spectacular Cases
e13
Figure 4.
Figure 2.
Figure 5.
Figure 3.
hernia sacs were reduced into the peritoneal cavity and temporarily sutured to the abdominal sidewall to prevent re-herniation, and a wound vacuum-assisted closure device was placed. After further resuscitation, the patient was taken back to the operating room for abdominal washout, and both hernias were repaired using the Bassini technique. Subsequently, a gastrojejunal tube was placed, and the abdomen was closed with bridging vicryl mesh (Figure 5). He also underwent tracheostomy for prolonged mechanical ventilation.
Spectacular Cases
ongoing retroperitoneal hemorrhage followed by right nephrectomy for hilum injury. The remaining missile tract through psoas muscle was hemostatic. A right thoracotomy was performed for ongoing hemorrhage from the right chest tube. Wedge resections of the upper and lower lobes and a formal middle lobectomy were completed. Vascular surgery identified a brachial artery injury near the bifurcation and performed a repair with ipsilateral basilic vein. On postoperative day 2, after resuscitation led by critical care intensivists, the patient was stable for completion right hemicolectomy, ileocolic anastomosis, cholecystectomy secondary to missile tract proximity, removal of balloon tamponade and abdominal closure. The course was complicated by left forearm compartment syndrome on postoperative day 2, requiring emergent volar and dorsal forearm fasciotomy and subsequent skin grafting by hand surgery. The patient was discharged home 4 weeks after admission with moderate sensory and motor deficits of his left hand. The patient survived these critical injuries through effective communication and collaboration among the involved disciplines. Damage Control Surgery: Not Just for Trauma Ornela A Dervishaj, MD, PGY3 Brooklyn Hospital Center, a Mount Sinai Medical Center Affiliate, Brooklyn, NY A 64-year-old male patient, 12 days after a hand-assisted laparoscopic right hemicolectomy for an ileocolic mass, presented to the emergency department in acute respiratory distress and altered mental status. After rapid sequence intubation, a surgical consult was obtained for abdominal distention. Initial evaluation revealed an overweight, soft abdomen with mild distention, and well-healing surgical scars. Labs revealed acute kidney injury with a creatinine of 7.5 mg/dL, and white blood cell count of 16.8. After initial resuscitation, a CT scan of the head, chest, abdomen, and pelvis was performed, and was significant for a left-lower-lobe infiltrate with pleural effusion and fluid in the right-lower quadrant of the abdomen, likely postoperative in nature. Empiric antibiotics were started for presumed pneumonia and patient was upgraded to the ICU. Sixteen hours after admission, the patient was noted to have worsening abdominal distention with feculent drainage from the incision and bladder pressure of 34 mmHg, confirming abdominal compartment syndrome. He was taken to the operating room and found to have feculent peritonitis secondary to a through-andthrough enterotomy in the jejunum and complete dehiscence of the ileocolic anastomosis. During the procedure the patient went into asystole, Advanced Cardiac Life Support protocol was initiated with return of spontaneous circulation in 10 minutes. This prompted a damage control approach at this initial surgery, where the enterotomies were closed using a GIA stapler (Covidien) and the abdomen remained open using a negative pressure system. The patient was brought back to the SICU and after further resuscitation and hemodialysis, returned to the operating room on postoperative day 2. No further injuries were identified, the jejunum was re-anastomosed, and an ileostomy was created. The patient endured a complicated postoperative course with septic shock, hypoxic brain injury, myocardial infarction, acute kidney injury, acute respiratory
J Am Coll Surg
distress syndrome, and developed multiple intra-abdominal collections. Despite this, the patient eventually recovered, was extubated on postoperative day 13, recovered full kidney and neurologic function and was discharged on postoperative day 32. Damage control surgery can be lifesaving in multiple organ failure due to an acute abdomen. Gastric Perforation Associated with Bilateral Inguinal Hernias Evan Fitz, MD General Surgery Resident, PGY3, Ray Chihara, MD, PhD General Surgery Resident, PGY8, Katie Jo Stanton-Maxey, MD Assistant Professor of Surgery Department of Surgery, Indiana University School of Medicine, Indianapolis, IN A 49-year-old male patient presented by ambulance to the county safety-net hospital complaining of severe abdominal pain after eating dinner. He was evaluated by the emergency department and found to have a rigid abdomen and enormously distended scrotum consistent with bilateral inguinal hernias, which he reported had been present for 10 years (Figure 1). The General Surgery team was urgently consulted for evaluation. He was significantly tachycardic and soon became unresponsive. He was intubated, and nasogastric tube placement returned several liters of enteric contents. Aggressive fluid resuscitation was initiated. Plain film radiography was obtained, revealing pneumoperitoneum and nearly the entire gastrointestinal tract except for a portion of the stomach contained within the scrotum (Figures 2 and 3). He was taken emergently to the operating room, where laparotomy was performed. The distal stomach, duodenum, as well as the head of the pancreas, were reduced from the right inguinal hernia. Nearly the entire small bowel and colon were reduced from the left inguinal hernia. The entire bowel was determined to be viable. There was massive contamination of the right paracolic gutter, secondary to an 11-cm perforation located on the lesser curvature of the stomach (Figure 4). This was repaired primarily. Due to the chronic nature of the hernias, there was a substantial loss of domain which prohibited abdominal closure. The large bilateral inguinal
Figure 1.
Vol. 222, No. 2, February 2016
Spectacular Cases
e13
Figure 4.
Figure 2.
Figure 5.
Figure 3.
hernia sacs were reduced into the peritoneal cavity and temporarily sutured to the abdominal sidewall to prevent re-herniation, and a wound vacuum-assisted closure device was placed. After further resuscitation, the patient was taken back to the operating room for abdominal washout, and both hernias were repaired using the Bassini technique. Subsequently, a gastrojejunal tube was placed, and the abdomen was closed with bridging vicryl mesh (Figure 5). He also underwent tracheostomy for prolonged mechanical ventilation.