Exploratomy Laparotomy of Doom. 2.

There's something about exploratory laparotmies that scares me. That 'tally ho, in we go' sort of idealism, we're going in, and damn it, we'll bag those bastards as we find 'em.

Tonight's case was admitted during my evening shift last night: she's initially been reported as an appendicitis, but I'm not convinced. The history is too long, too few of the signs and symptoms present. Auscultation is suspiciously tinkling, so I'm not surprised to see that the AXR, when it comes back, is tarred by huge black slugs of dilated small bowel. Blocked; but where?

The CT done while I am deeply asleep this afternoon shows nothing concrete. So I'm tugging on a retractor tonight, watching feet of vast contused bowel being pulled hesitantly from her midline; omentum plastered to the site of an old scar. It takes half an hour to get a view of bowel, watching Richard snip carefully through endless masses of fibrous material to get in.

It smells awful. Awful. I'm expecting to see litres of faeculant fluid in the peritoneum, but it's not there. And where we expect to find her appendix, there is simply a messy looking hole where the entire appendage has just disintegrated into nothing. That blob is matted to the surrounding bowel, leaving it red and angry and looking initially non viable.

It picks up, happily. What now? Richard asks me. I'm stumped. Resect? Right hemicolectomy? Defunction? He rings up the consultant, though I can't help feeling he already knows what to do. The consultant agrees with his plan; a huge size 30 Robinson's drain is left in the region, and the rest left exactly as it is.

Primum Non Nocere, again, I think. Richard self deprecates about 'The Gillies Procedure. You put in a huge drain, big as you can, then run.' I can't help but laugh, the way he does it, but looking to that abdomen, diagnosed and closed, I can't help but feel that the real job is just knowing when to step back.

Sacced

Assisting Alex with a right inguinal hernia today; a unusually educational experience because her endearing utter lack of self esteem means she works harder than most to make sure the anatomy is absolutely clear - and because she does this to make it clear in her mind, it is clear in my mind, too.

This isn't a Bog Standard; it becomes clear on opening it up that there is no bowel to be seen, just a large lipoma and no internal oblique defect. This is an indirect hernia, with all the contents trapped clearly within the fascial lining surrounding the cord.

I'm confused until she explains it later. For some reason I have convinced myself that the vas has a peritoneal lining, whereas she keeps usiing the term 'fascial'. We track it back mentally, and I'm ashamed to concede she's right (as usual, bloody women.)

Will have to revise the anatomy again, I suppose.

Hardly bodes well for the MRCS part 2 I sat yesterday...

The perf

Every once in a while you end up with a patient so oblique in their presentation that discerning symptoms is a murky affair even before you get to the signs. I end up with one such patient at the end of a busy take and try and review what the PRHO has told me; it all sounds a bit fudgy. Non specific abdo pain on a background of chronic pain. Dementia. A partially treated UTI.

The PRHO feels the abdomen is tender and has guarding with peritonism. I distract the patient and palpate through the guarding. Tender in the right iliac fossa yes, but not peritonitic, I’m content. Afebrile, a low B/P that has come up with resuscitation, and a raised WCC – about 20. Anyhow, at ASA Grade 3 with raging CCF, it’s unlikely we could do anything for say, acute cholecystitis, anyway.

I conclude she probably has a partially treated UTI, and script a letter while waiting for radiology to come back. She’ll go home and finish a course of trimethoprim away from this nasty place. I’m pleased at myself for holding her hand, making her smile, avoiding an unnecessary admission for a nice lady.

I’m at home when the radiograph comes back to the juniors with about half a litre of air under the right hemidiaphragm and she’s admitted to the ward. True, we can’t offer anything but a bed, but it’s arguably better to have morphine than go without. I apologise to the family the next morning for rushing into a hasty diagnosis without waiting, and feel an inch tall under their generous magnanimity.

She dies three days later.

Exploratory Laparotomy of Doom

FS is sick. The sort of sick that makes me want to rush for the tea pot and pour a sympathy brew for him for lack of any other real ideas; but when I do manage to get a syringe into his hardly pumping right radial artery (Allen's test only just acceptable as I later document) he comes back with the result I don't want to smell; Lactate 7.7.

"Yep, 7.7" I say to the ITU outreach person, who gets down panting about three and a half minutes later with not one, but two anaesthetists in tow. Mr FS is looking a tired, mottled lump in the corner and hyperventilating harshly while the HCA fusses over his bead linen, completely oblivious to the gravity of his condition.

I learn a lesson about belief in my own clinical acumen today. It's an isolated result, this rising lactate, with no obvious septic focus. Something acute has clealy occurred to drive it up from a normal value 48 hours earlier. But what? It's not clear looking at his abdomen that this is it; diffusely tender, but not, I convince myself, peritonitic.

For whatever reason, the registrar differs over this point, which alters the management utterly. Rather than being a candidate for a scan, he's prepped for an emergency laparotomy. The anaethetists float upstairs with that languid pre-theatre expression that they have mastered over time, and I float off to do more on call jobs.

The laparotomy is negative. Dilated small bowel loops, certainly, and I think mottled but not seriously so. A little bloodstained ascites. The anaesthetist looks brightly over the drapes about a half hour in, omentum and guts pouring out of a midline incision, and declares nonchalently that the lactate has returned to a normal value. The registrar looks like he has swallowed a jellyfish.

An unecessary procedure for a critically ill man? We'll never know. But I suspect that he might have done with some judicious resuscitation and observation rather than diving in, especially when the clinical signs were so contrivertible.

Do you catch these patients early? Do you act on your - no pun intended - gut instinct and catch them before things go down hill? Or run the gauntlet and risk a normal laparotomy? I suppose I'll have to wait until I'm a reg to know with any semi-certainty. But today I have a little more faith in my own ability to assess an abdomen.

Some small consolation, if not for poor FS, in that, perhaps.