Praveen Ravi
Contributor
OPERATION: Removal of temporary abdominal VAC dressing, re-exploratory
laparotomy, partial omentectomy x2, repair of small bowel serosal tear,
abdominal washout, abdominal fascia closure, VAC dressing to the skin.
victim of a gunshot wound to the abdomen 2 days before. The patient
underwent exploratory laparotomy he was found to have an injury
to the gallbladder and anterior wall of the stomach and underwent cholecystectomy,
gastrorrhaphy, and
repair of abdominal wall injuries x2. He had temporary abdominal closure.
The patient continued resuscitation in the ICU overnight and returns to the
operating room today for abdominal washout and possible fascial closure.
Informed surgical consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite,
where he was placed in a supine position. General endotracheal anesthesia
was induced. A proper time-out procedure was conducted. The patient did
receive preoperative Ancef. Bilateral lower extremity sequential
compression devices were placed. The patient already had a Foley catheter
in place and had peripheral IV lines in place. Operation began by removing
the outer layer of the VAC dressing including the outer sponge. The
patient's abdomen was then prepped and draped in the usual sterile fashion.
Operation began by removing the inner sponge and the inner perforated
plastic dressing. Once this was done, I identified a small arterial bleeder
in the subcutaneous tissue. This was addressed with Bovie electrocautery.
In addition, the patient had a small muscle arterial bleeder. I attempted
to Bovie this, however, it continued to bleed and I placed a 3-0 Vicryl
suture to ligate it. At this point, I eviscerated the small bowel and ran
the small bowel from the ligament of Treitz to the ileocecal valve. There
were several areas of mild contusions to the small bowel, however, there
were no perforations or areas of duskiness or necrosis, the mesentery was
intact, no injuries were noted. The patient did have a very small, less than 0.5 cm
serosal tear to the small bowel. This was reapproximated using 3-0 Vicryl
in a Lembert fashion. I inspected the colon from the cecum all the way to
the sigmoid colon. There was no noted injury. I did identify the appendix,
this was free of injury. I inspected the stomach. The stomach had evidence
of prior repair. This repair was intact. There was no bleeding. I
inspected the liver. The liver had a grade 2 laceration, which was
hemostatic, there was no evidence of bile leak or bile staining.
I inspected the spleen, this was free of injury. I inspected the abdominal wall
on either side of patient's abdomen, the suture repairs were intact. I then irrigated the
patient's abdomen with warm normal saline until effluent ran clear. The
patient had two small areas on the omental edge, that appeared necrotic.
These were clamped. Metzenbaum scissors were used to transect the small
area of omentum and 3-0 Vicryl was used to ligate the omental edge. Once
again, I inspected the patient's stomach and had the anesthesiologist direct
the OG tube down slightly further into the stomach. I ran the small bowel
once again. There was no further injury noted. I then returned the small
bowel to the patient's abdomen, irrigated with warm normal saline once again
until effluent ran clear. I then covered the small bowel with the patient's
omentum and proceeded to close the fascia. The fascia was closed with two 0
PDS running sutures, one directed from a cephalad to caudad fashion and one
directed from a caudad to the cephalad direction, these met just below the
umbilicus and were secured down. There was no fascial defect noted. The
fascia was closed. The abdominal incision was covered with a sterile towel and
intraoperative abdominal films (AP and LAT) were obtained.
I then irrigated the patient's subcutaneous tissue and
placed a VAC dressing to the subcutaneous tissue and skin. This was
connected to the vacuum suction device. There was good seal and no leak. I
then turned my attention to the patient's bilateral sides. He had two
small wounds. The packing in these wounds were removed. I irrigated these
wounds with normal saline and then placed 1 inch packing and covered these
with sterile bulky dressings. The patient tolerated the procedure well.
All the counts were reported as correct.
laparotomy, partial omentectomy x2, repair of small bowel serosal tear,
abdominal washout, abdominal fascia closure, VAC dressing to the skin.
victim of a gunshot wound to the abdomen 2 days before. The patient
underwent exploratory laparotomy he was found to have an injury
to the gallbladder and anterior wall of the stomach and underwent cholecystectomy,
gastrorrhaphy, and
repair of abdominal wall injuries x2. He had temporary abdominal closure.
The patient continued resuscitation in the ICU overnight and returns to the
operating room today for abdominal washout and possible fascial closure.
Informed surgical consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite,
where he was placed in a supine position. General endotracheal anesthesia
was induced. A proper time-out procedure was conducted. The patient did
receive preoperative Ancef. Bilateral lower extremity sequential
compression devices were placed. The patient already had a Foley catheter
in place and had peripheral IV lines in place. Operation began by removing
the outer layer of the VAC dressing including the outer sponge. The
patient's abdomen was then prepped and draped in the usual sterile fashion.
Operation began by removing the inner sponge and the inner perforated
plastic dressing. Once this was done, I identified a small arterial bleeder
in the subcutaneous tissue. This was addressed with Bovie electrocautery.
In addition, the patient had a small muscle arterial bleeder. I attempted
to Bovie this, however, it continued to bleed and I placed a 3-0 Vicryl
suture to ligate it. At this point, I eviscerated the small bowel and ran
the small bowel from the ligament of Treitz to the ileocecal valve. There
were several areas of mild contusions to the small bowel, however, there
were no perforations or areas of duskiness or necrosis, the mesentery was
intact, no injuries were noted. The patient did have a very small, less than 0.5 cm
serosal tear to the small bowel. This was reapproximated using 3-0 Vicryl
in a Lembert fashion. I inspected the colon from the cecum all the way to
the sigmoid colon. There was no noted injury. I did identify the appendix,
this was free of injury. I inspected the stomach. The stomach had evidence
of prior repair. This repair was intact. There was no bleeding. I
inspected the liver. The liver had a grade 2 laceration, which was
hemostatic, there was no evidence of bile leak or bile staining.
I inspected the spleen, this was free of injury. I inspected the abdominal wall
on either side of patient's abdomen, the suture repairs were intact. I then irrigated the
patient's abdomen with warm normal saline until effluent ran clear. The
patient had two small areas on the omental edge, that appeared necrotic.
These were clamped. Metzenbaum scissors were used to transect the small
area of omentum and 3-0 Vicryl was used to ligate the omental edge. Once
again, I inspected the patient's stomach and had the anesthesiologist direct
the OG tube down slightly further into the stomach. I ran the small bowel
once again. There was no further injury noted. I then returned the small
bowel to the patient's abdomen, irrigated with warm normal saline once again
until effluent ran clear. I then covered the small bowel with the patient's
omentum and proceeded to close the fascia. The fascia was closed with two 0
PDS running sutures, one directed from a cephalad to caudad fashion and one
directed from a caudad to the cephalad direction, these met just below the
umbilicus and were secured down. There was no fascial defect noted. The
fascia was closed. The abdominal incision was covered with a sterile towel and
intraoperative abdominal films (AP and LAT) were obtained.
I then irrigated the patient's subcutaneous tissue and
placed a VAC dressing to the subcutaneous tissue and skin. This was
connected to the vacuum suction device. There was good seal and no leak. I
then turned my attention to the patient's bilateral sides. He had two
small wounds. The packing in these wounds were removed. I irrigated these
wounds with normal saline and then placed 1 inch packing and covered these
with sterile bulky dressings. The patient tolerated the procedure well.
All the counts were reported as correct.