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You are here: Home / 09. Medical/Surgical / Emergency Abdominal Surgery

Emergency Abdominal Surgery

July 14, 2011 by CrashMaster

Emergency Abdominal Surgery

 

Schein’s Common Sense Emergency Abdominal Surgery

 

Management Options

immediate operation (surgery now)

pre-op prep and operation (surgery in am)

conservative management

discharge

 

Clinical Patterns

 

Abdominal Pain and Shock

ruptured AAA ruptured ectopic

(abdominal apoplexy)

 

also severe obstruction, acute mesenteric ischemia, and severe pancreatitis

 

 

 

Generalized Peritonitis

umbilicus is the shallowest portion of the abdominal wall

perforated ulcer, perforated colon, and perforated appendicitis

always rule-out pancreatitis with a lipase, b/c an operation in this case will do nobody any good.

 

Localized Peritonitis

acute appendicitis

acute cholecystitis

acute diverticulitis

 

when the diagnosis is uncertain, the patients benefit from observation

palpable mass in the rlq is a appendicieal phlegmon and surgery may not be indicated

 

Intestinal Obstruction

the earlier and more severe the vomiting, the more proximal the obstruction

vomiting and colicky pain are SBO

constipation and gross distension are colonic

simple adhesive sbo does not need an op

pitfalls

look for an incarcerated femoral hernia in obese females

elderly patient with partial sbo which resolves and then returns with a tumor

elderly lady with resolving sbo who comes back with gallstone ileus

terminal ileum bezoar in patients with history of gastric surgery

 

medical causes

inferior wall mi

dka

 

Optimizing a Patient

remember, anesthesia takes away the body’s compensation for shock

make them have a reasonable urine output 1/2 cc/kg

that being said, drowning patients leads to post-op misery

 

preop abx

ther or prophylactic

should already be in the bloodstream before the scalpel touches the belly

bugs are consistent:

endotoxin generating facultative anaerobes like e.coli

and obligate anaerobes like b. fragilis

give higher doses in the face of massive fluid resus

 

examine after anes. and before incising

 

incision of indecision

if going in through old incision, try to start a few centimeters below and enter peritoneum through virgin abdomen

 

trauma lap

long incision

remove small bowel

suck out blood (preferably with cell saver)

pack four quads

 

if you release massive IAH, pt will decompensate. Pause, manually compress the aorta and let anesthesia catch-up

 

the peritoneum consists of two compartments

supracolic

infracolic

divided by transverse (mesocolon)

 

Peritonitis

primary peritonitis is caused by micro-organisms originating from a source outside of the abdomen

strep from genital tract

e. coli from blood

staph from PD cath

 

lap of on advanced cirrhotic is an autopsy in vivo

secondary peritonits-from ruptured or inflamed abdominal viscus

 

Contamination-spillage of contents without inflammation

Resectable Intra abd infection-

non-resectable

 

Source control****

 

 

Anastomosis

 

The incidence of leakage is identical irrespective of the method used to long as the bowel will used the anastomosis is without tension is water and airtight

the single layer anastomosis is associated with the lowest incidence of stricture formation

monofilament suture like PDS and prolene associated with less inflammation when used to so continuously, there are also able to adjust the tension around the entire circumference of the anastomosis

 

if you primarily anastomose swollen bowel,the anastomosis can fail when the edema resolves

 

 

Closure

use non-absorbable-nylon or prolene

or delayed-PDS or maxon

monofilament

 

do not use rapidly absorbed material such as vicryl or dexon

monofilament slides better and does not saw the tissue

mass closure of abdomen is fine-take large bites at least 1 cm away with small bites and include the muscle

 

or close posterior and then anterior fascia with one running suture

 

can leave the subcutaneous tissue alone, no deadspace reduction necessary

 

if it looks all right, then it’s too tight!

 

pre-closure checklist

hemostasis perfect

source control

peritoneal toilet

anastamosis viable

small bowel in place below transverse colon

omentum placed between incision and intestine

fascial defects are all closed

drains in place

feeding jejunosostomy if indicated

should the abdomen actually be closed

 

while the abdomen is open, you control it; when it is closed, it controls you.

 

Fistuli

 

 

post-op infection

look for the pneumonia–inside the abdomen

 

 

old folks do horribly with ileostomies

 

 

 

 

 

 

 

 

 

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Filed Under: 09. Medical/Surgical, gastrointestinal


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