ksb0211
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POSTOPERATIVE DIAGNOSES
Sepsis, bandemia. CT scan findings suggestive of free air. Necrotizing pancreatitis.
OPERATION PERFORMED
Exploratory laparotomy with intraoperative upper endoscopy, decompression of the small bowel, intra-abdominal lavage, placement of needle catheter feeding jejunostomy, retroperitoneal peripancreatic needle aspiration.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room after attainment of sufficient general anesthesia. He was pretreated with antibiotics and prepped and draped in the usual sterile fashion. Made a midline incision starting from the xiphoid down to the umbilicus, got into the abdominal cavity. We found some air as we got in. There was turbid fluid present, no frank pus. The operative field because of the necrotizing pancreatitis was grossly distorted with the pancreas pushing the stomach forward and the duodenum sort of posteriorly as you might expect if you had inflated say a soccer ball in the retroperitoneum. Looked down in the duodenum, The gallbladder was visualized. Clearly this was not an opportunity to remove this gallbladder as the anatomy was markedly distorted into the porta and we went ahead and elected to let that go for the time being. Aspirated the fluid that was down there and then brought some of the omentum down using the Harmonic scalpel. It was adhesed up against some of the gallbladder but when we did this, we could look down into the Morison space and see the duodenum but we really did not see a perforation. There was a great deal of saponification in the retroperitoneum. Again, this made visualization of the area very difficult. We did not see any air in the retroperitoneum. We repositioned the NG tube, got it through the duodenum and as we were doing that got methylene blue both into the stomach and actually into the duodenum to see if we could see a leak. We were looking at this area and really could not find a perforation. The field was so distorted again, it made visualization difficult. We felt over the stomach similar things were at large here. The pancreas had pushed the stomach forward, all this phlegmon in the retroperitoneum, and at this point we tried to see the top of the stomach, thinking maybe we had a more peripheral proximal perforation. Did not find anything there. Next, we run the small bowel and there was a great deal again of the saponification coating the small bowel, really into the mesentery most of all, all the fat bearing circumstances. Sent off some for frozen section, but it was pretty clear that this was saponification. Mobilized the small bowel and really took down an area via the saponification, was probably causing a partial bowel obstruction. We could see distal collapse proximal dilatation and at this point, we reconciled that. Looked at the small bowel, ran it down to the cecum and did not find anything, felt down in the lower portion of the abdomen, did not find any pus, nothing down there to suggest frank diverticulitis and so we were left without a good explanation as to why this patient might have had free air. At this point we decided what we would do is we would go up and bring the gastroscope in, clamped the patient's intestine to ligament of Treitz and we did just that. Went in with a gastroscope, had a look at the stomach, did not see anything. There were no overt ulceration. We insufflated at the duodenum and then went down the duodenum, probably down to the 3rd portion of duodenum. Got a pretty good examination of the duodenum and did not see anything to suggest an ulceration with perforation sitting in the middle of it and at this point, we were at loss to explain where this free air came from. We filled the area with fluid, looked both up at the stomach to see if there was a leak in that area, looking down below to see if there was a leak down in the right gutter. There was nothing that we could see and at this point we were left without a good reason for why this patient had free air but I can say that preoperatively he had become more tachycardic. He had run his bands up to 24. All of this fit with a picture of perhaps a "perf" and although we could not find it we were at a loss to know why that was the case. Having done all this, we elected just to drain the patient. There was incidental phone call from Dr. XXXXX from University of XXXXX and he was good enough to give us a little direction in the course of the case. This did not represent a consultation, it was more of a discussion with him about the findings at the time of the surgery and he suggested that we should aspirate some of the retroperitoneal fluid. We did so in 2 different locations bringing back some turbid fluid but not much else. At this point, we sent that off for culture and Gram stain. Irrigated the abdominal cavity with about 4 L of fluid, replaced the omentum, but not before introducing a needle catheter feeding jejunostomy into a portion of jejunum there, it lie nicely up against the abdominal wall, tunneled it using the needle to go through the wall of the jejunum, advancing the wire and the catheter into the jejunum, pushing it down about 30 cm down, removing the needle, then taking another needle going through the anterior abdominal wall, bringing the catheter through. We did tunnel the needle into the small bowel and then brought it up to the insertion site with two 2-0 silk sutures to hold the cannula in place. Once that was done, we covered the area with omentum and secured that to the abdominal wall as well into the bowel to make sure we had a nice fixation so it would not rotate. At this point, we irrigated, aspirated, placed a Jackson-Pratt into Morrison space and turned our attention to closure. We closed with double stranded #1 PDS, followed by irrigation, followed by skin staples. The patient did tolerate the procedure well. We also secured the needle catheter feeding jejunostomy removing the J wire.
Sepsis, bandemia. CT scan findings suggestive of free air. Necrotizing pancreatitis.
OPERATION PERFORMED
Exploratory laparotomy with intraoperative upper endoscopy, decompression of the small bowel, intra-abdominal lavage, placement of needle catheter feeding jejunostomy, retroperitoneal peripancreatic needle aspiration.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room after attainment of sufficient general anesthesia. He was pretreated with antibiotics and prepped and draped in the usual sterile fashion. Made a midline incision starting from the xiphoid down to the umbilicus, got into the abdominal cavity. We found some air as we got in. There was turbid fluid present, no frank pus. The operative field because of the necrotizing pancreatitis was grossly distorted with the pancreas pushing the stomach forward and the duodenum sort of posteriorly as you might expect if you had inflated say a soccer ball in the retroperitoneum. Looked down in the duodenum, The gallbladder was visualized. Clearly this was not an opportunity to remove this gallbladder as the anatomy was markedly distorted into the porta and we went ahead and elected to let that go for the time being. Aspirated the fluid that was down there and then brought some of the omentum down using the Harmonic scalpel. It was adhesed up against some of the gallbladder but when we did this, we could look down into the Morison space and see the duodenum but we really did not see a perforation. There was a great deal of saponification in the retroperitoneum. Again, this made visualization of the area very difficult. We did not see any air in the retroperitoneum. We repositioned the NG tube, got it through the duodenum and as we were doing that got methylene blue both into the stomach and actually into the duodenum to see if we could see a leak. We were looking at this area and really could not find a perforation. The field was so distorted again, it made visualization difficult. We felt over the stomach similar things were at large here. The pancreas had pushed the stomach forward, all this phlegmon in the retroperitoneum, and at this point we tried to see the top of the stomach, thinking maybe we had a more peripheral proximal perforation. Did not find anything there. Next, we run the small bowel and there was a great deal again of the saponification coating the small bowel, really into the mesentery most of all, all the fat bearing circumstances. Sent off some for frozen section, but it was pretty clear that this was saponification. Mobilized the small bowel and really took down an area via the saponification, was probably causing a partial bowel obstruction. We could see distal collapse proximal dilatation and at this point, we reconciled that. Looked at the small bowel, ran it down to the cecum and did not find anything, felt down in the lower portion of the abdomen, did not find any pus, nothing down there to suggest frank diverticulitis and so we were left without a good explanation as to why this patient might have had free air. At this point we decided what we would do is we would go up and bring the gastroscope in, clamped the patient's intestine to ligament of Treitz and we did just that. Went in with a gastroscope, had a look at the stomach, did not see anything. There were no overt ulceration. We insufflated at the duodenum and then went down the duodenum, probably down to the 3rd portion of duodenum. Got a pretty good examination of the duodenum and did not see anything to suggest an ulceration with perforation sitting in the middle of it and at this point, we were at loss to explain where this free air came from. We filled the area with fluid, looked both up at the stomach to see if there was a leak in that area, looking down below to see if there was a leak down in the right gutter. There was nothing that we could see and at this point we were left without a good reason for why this patient had free air but I can say that preoperatively he had become more tachycardic. He had run his bands up to 24. All of this fit with a picture of perhaps a "perf" and although we could not find it we were at a loss to know why that was the case. Having done all this, we elected just to drain the patient. There was incidental phone call from Dr. XXXXX from University of XXXXX and he was good enough to give us a little direction in the course of the case. This did not represent a consultation, it was more of a discussion with him about the findings at the time of the surgery and he suggested that we should aspirate some of the retroperitoneal fluid. We did so in 2 different locations bringing back some turbid fluid but not much else. At this point, we sent that off for culture and Gram stain. Irrigated the abdominal cavity with about 4 L of fluid, replaced the omentum, but not before introducing a needle catheter feeding jejunostomy into a portion of jejunum there, it lie nicely up against the abdominal wall, tunneled it using the needle to go through the wall of the jejunum, advancing the wire and the catheter into the jejunum, pushing it down about 30 cm down, removing the needle, then taking another needle going through the anterior abdominal wall, bringing the catheter through. We did tunnel the needle into the small bowel and then brought it up to the insertion site with two 2-0 silk sutures to hold the cannula in place. Once that was done, we covered the area with omentum and secured that to the abdominal wall as well into the bowel to make sure we had a nice fixation so it would not rotate. At this point, we irrigated, aspirated, placed a Jackson-Pratt into Morrison space and turned our attention to closure. We closed with double stranded #1 PDS, followed by irrigation, followed by skin staples. The patient did tolerate the procedure well. We also secured the needle catheter feeding jejunostomy removing the J wire.