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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