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.
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.
posted by Bas at 3:22 PM
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