11 Bere 2024
In the last day at Bere I did two intestinal repairs. now that’s something often done by general surgeons. One was a “usual” case and one “unusual”
First with the “usual”. I was called to see a 10 year old boy who was on pediatrics after a fall on a bicycle. At first I thought I understood he had fallen from a tree on a bicycle. Then I saw the tell tale sign of a circle impression on his right abdomen. A handlebar into the abdomen. he had a rigid abdomen with peritoneal signs. So I told them to take him over to the OR and start an IV on him. He will need to be one of the next ones operated on. I suspect that he may have pinched a piece of intestine between the handlebar and his spine. This occurred a couple days ago.
As I open his abdomen i immediately get a lot of stool and pus and free air. I suck out all the stool i can and then wash out his abdomen with a lot of saline. Once it’s coming out fairly clear, I start looking for the hole in the intestine. I find it mid-jejunum (small intestine). He has a hole one side of the piece of small bowel and a hole on the opposite side and a small hematoma in the mesentery to that area. Definitely a pinched piece of intestine making the hole. So i freshen up the edges of the holes and then suture them closed. I do a single interrupted closure, meaning one layer of sutures to close the holes. It takes about an hour. Finally the holes are closed and we close up the abdomen.
The other one (unusual) was a woman who i had been watching over the week who presented to Bere about two months after a surgery at another place where she had some surgery where they did something and may had cut adhesions. The patient and family doesn’t know and it’s not written in her book in a legible way. They said shes been vomiting and cant keep food down two months. Now that story makes me feel suspicious. So i admit her and observe. I give her nausea medicine and she seems to do better and eats some food. Her stool is hard and she has firm areas in her abdomen that changes position- like intestine moving. So I decide to stimulate her bowels with medicine to see if she can pass the stool and if thats causing the problem. I had done an Xray of her abdomen that didn’t show obstruction but I was a little worried about a partial obstruction. The surgical ward nurse came to tell me shes was vomiting a lot after this medicine. It was my last day and I had watched her. I didn’t wan to leave her for the other surgeon after I’d watched her so long- so I said to bring her to the OR and keep her NPO. I was worried about operating on her because she was so thin she looked like a starvation person. Meaning that I wondered if she had enough nutrition to heal a surgery!! Or would she just leak with an enterocutaneous fistulae and die? I felt forced to do something….
As I cut through her skin I immediately came to fascia. No fat whatsoever. She is starving to death! I entered the abdomen and found dilated small bowel and decompressed small bowel. Definitely an obstruction. I started at the top where the dilated bowel was and followed it down. I found an area of previous resection with that being the transition point between dilated and non-dilated bowel. So to take out that section or just bypass it. If I took it out I’d have a huge anastomosis to do and it would take a long time. If i did a bypass, attaching the one piece to the other I could make it whatever size was needed and leave it at that. So i did a side to side anastomosis. I cut each piece of intestine and started sewing them together with an opening in between. This took about an hour. The anastomosis looked good and as soon as I unclamped the intestine, fluid started going through. Yay! I closed her up and we went on to other surgeries.
Now a few days later she is post op day 4 and she is able to eat and shes moving her bowels. And so is the boy of earlier in this message. Im so grateful. Always after an anastomosis of intestines Im not at peace till about a week later when everything is working well and there is no anastomotic leak or problems. Im glad to hear they are doing well. Thank you Dr. Jorla for letting me know.
Greg