amanda19791
Networker
Need some advice on the patient with enterostomy with foreign body. Patient swallow a BB and thought to have lodged in throat; after EGD was done the BB was located in the walls of jejunum.
Procedure:
Multiple enterotomies in the small bowel from intraluminal magnet adherence. All the magnets were removed, confirmed by fluoroscopy; total fluoroscopy time was 4 seconds.
Indications: This is a 4-year-old, otherwise healthy boy who presented with complaints of abdominal pain and vomiting. Abdominal x-ray was performed that demonstrated a foreign body thought to be in the stomach. Abdominal x-ray was repeated and review of the 2 films demonstrated a radiopaque beaded. Concern based upon the abdominal exam, his history, and the findings on x-ray that these magnets had passed through the pylorus and may be causing intraluminal perforations schedule the child for urgently EGD and possible laparotomy.
Details of procedure: The patient was identified and placed in the supine position on the operating table. Adequate anesthesia was induced. Timeout was performed and all present were in agreement.
A flexible endoscope was passed into the mouth and down into the stomach to the esophagus. No foreign bodies were identified in the stomach. There was no evidence of gastritis or irritation. The scope was passed into the duodenal bulb and then into the third portion of the duodenum and no foreign bodies were noted. The scope was removed, suctioning to desufflate the stomach and esophagus and no mucosal abnormalities were noted. Because the foreign body was not found in the stomach we decided to proceed with laparotomy. The child received intravenous antibiotics from the anesthetist and the abdomen was prepped and draped in sterile fashion. A midline incision was made in the umbilical skin and the pre-existing umbilical hernia defect was identified. The fascia was opened superior and inferior from the umbilical defect to enter the abdominal cavity. The small bowel was eviscerated and I immediately noted a defect in the antimesenteric side wall of the jejunum with a small magnet the size and shape of a BB. The serosa was opened further and the magnet was removed. The enterotomy was closed with interrupted 4-0 Vicryl suture. I then proceeded to eviscerate more of the jejunum and noted two additional enterotomies. The first was in the sidewall of the jejunum and this was associated with a long serosal tear. There were two small magnets at this point which were removed and the enterotomy was closed with interrupted 4-0 Vicryl suture; the 3 cm serosal tear was approximated with interrupted 4-0 Vicryl suture in Lembert fashion. The next enterotomy was noted more distal but still in the jejunum and was on the mesenteric wall, again associated with a long serosal tear. One small magnet was removed from this and the enterotomy was closed with interrupted 4-0 Vicryl suture, again closing the serosal tear in Lembert fashion. I then eviscerated more bowel and needed to extend my umbilical incision superior about 1 cm and this allowed me to bring up the ileum where I discovered the majority of the magnets which were contiguous but looped together in the ileum, adhering the proximal ileum to itself in such a way as to cause a very long line of enterotomies along the mesenteric border with potential compromise of the blood supply. I decided to resect this short segment of bowel instead of trying to remove the magnets and repair the multiple mesenteric enterotomies. Bowel clamps were placed on either side of the area in question and the bowel was divided. The LigaSure was used to take down the mesentery for this 10 cm segment. The magnets were removed from the specimen. I then proceeded to perform a handsewn, single layer small bowel anastomosis with 4-0 Vicryl suture placing all the knots on the outside. The anastomosis was checked for integrity by milking enteric contents across and there was no leak; the anastomosis was widely patent. The mesenteric defect was closed with interrupted 4-0 Vicryl suture. I then eviscerated the remainder of the bowel bringing the proximal cecum out of the wound and then very carefully inspected the bowel from the cecum retrograde to the ligament of Treitz and no other anomalies or foreign bodies were noted. The anastomoses and enterotomies were all inspected for integrity and I was satisfied with the closures. The bowel was then returned to the abdominal cavity and fluoroscopy was used to confirm that no other foreign bodies were present. The anesthetist pass a nasogastric tube and placement was confirmed with fluoroscopy. The abdomen was copiously irrigated with warm normal saline and excess fluid was suctioned out of the abdominal cavity. The fascia was closed with a running 2-0 PDS StrataFix suture and the wound was irrigated. The dermis was approximated with interrupted 4-0 Vicryl suture and the skin closed with a running 4-0 Monocryl suture. The wound was infiltrated with Marcaine and Dermabond was applied as a sterile dressing. I had palpated the bladder prior to closure and so I decided to place a Foley catheter and 50 mL of urine was removed from the bladder; the Foley was removed. The child was extubated and taken to recovery room in stable condition. The procedure was well tolerated, and there were no complications.
Estimated blood loss: 5 mL
Disposition: The patient transferred to the PACU, stable and extubated.
Instrument, needle and sponge counts: Correct
Specimens: Small bowel
As the attending surgeon, I was present for and supervised or performed all aspects
Procedure:
Multiple enterotomies in the small bowel from intraluminal magnet adherence. All the magnets were removed, confirmed by fluoroscopy; total fluoroscopy time was 4 seconds.
Indications: This is a 4-year-old, otherwise healthy boy who presented with complaints of abdominal pain and vomiting. Abdominal x-ray was performed that demonstrated a foreign body thought to be in the stomach. Abdominal x-ray was repeated and review of the 2 films demonstrated a radiopaque beaded. Concern based upon the abdominal exam, his history, and the findings on x-ray that these magnets had passed through the pylorus and may be causing intraluminal perforations schedule the child for urgently EGD and possible laparotomy.
Details of procedure: The patient was identified and placed in the supine position on the operating table. Adequate anesthesia was induced. Timeout was performed and all present were in agreement.
A flexible endoscope was passed into the mouth and down into the stomach to the esophagus. No foreign bodies were identified in the stomach. There was no evidence of gastritis or irritation. The scope was passed into the duodenal bulb and then into the third portion of the duodenum and no foreign bodies were noted. The scope was removed, suctioning to desufflate the stomach and esophagus and no mucosal abnormalities were noted. Because the foreign body was not found in the stomach we decided to proceed with laparotomy. The child received intravenous antibiotics from the anesthetist and the abdomen was prepped and draped in sterile fashion. A midline incision was made in the umbilical skin and the pre-existing umbilical hernia defect was identified. The fascia was opened superior and inferior from the umbilical defect to enter the abdominal cavity. The small bowel was eviscerated and I immediately noted a defect in the antimesenteric side wall of the jejunum with a small magnet the size and shape of a BB. The serosa was opened further and the magnet was removed. The enterotomy was closed with interrupted 4-0 Vicryl suture. I then proceeded to eviscerate more of the jejunum and noted two additional enterotomies. The first was in the sidewall of the jejunum and this was associated with a long serosal tear. There were two small magnets at this point which were removed and the enterotomy was closed with interrupted 4-0 Vicryl suture; the 3 cm serosal tear was approximated with interrupted 4-0 Vicryl suture in Lembert fashion. The next enterotomy was noted more distal but still in the jejunum and was on the mesenteric wall, again associated with a long serosal tear. One small magnet was removed from this and the enterotomy was closed with interrupted 4-0 Vicryl suture, again closing the serosal tear in Lembert fashion. I then eviscerated more bowel and needed to extend my umbilical incision superior about 1 cm and this allowed me to bring up the ileum where I discovered the majority of the magnets which were contiguous but looped together in the ileum, adhering the proximal ileum to itself in such a way as to cause a very long line of enterotomies along the mesenteric border with potential compromise of the blood supply. I decided to resect this short segment of bowel instead of trying to remove the magnets and repair the multiple mesenteric enterotomies. Bowel clamps were placed on either side of the area in question and the bowel was divided. The LigaSure was used to take down the mesentery for this 10 cm segment. The magnets were removed from the specimen. I then proceeded to perform a handsewn, single layer small bowel anastomosis with 4-0 Vicryl suture placing all the knots on the outside. The anastomosis was checked for integrity by milking enteric contents across and there was no leak; the anastomosis was widely patent. The mesenteric defect was closed with interrupted 4-0 Vicryl suture. I then eviscerated the remainder of the bowel bringing the proximal cecum out of the wound and then very carefully inspected the bowel from the cecum retrograde to the ligament of Treitz and no other anomalies or foreign bodies were noted. The anastomoses and enterotomies were all inspected for integrity and I was satisfied with the closures. The bowel was then returned to the abdominal cavity and fluoroscopy was used to confirm that no other foreign bodies were present. The anesthetist pass a nasogastric tube and placement was confirmed with fluoroscopy. The abdomen was copiously irrigated with warm normal saline and excess fluid was suctioned out of the abdominal cavity. The fascia was closed with a running 2-0 PDS StrataFix suture and the wound was irrigated. The dermis was approximated with interrupted 4-0 Vicryl suture and the skin closed with a running 4-0 Monocryl suture. The wound was infiltrated with Marcaine and Dermabond was applied as a sterile dressing. I had palpated the bladder prior to closure and so I decided to place a Foley catheter and 50 mL of urine was removed from the bladder; the Foley was removed. The child was extubated and taken to recovery room in stable condition. The procedure was well tolerated, and there were no complications.
Estimated blood loss: 5 mL
Disposition: The patient transferred to the PACU, stable and extubated.
Instrument, needle and sponge counts: Correct
Specimens: Small bowel
As the attending surgeon, I was present for and supervised or performed all aspects