Emergency Abdominal Surgery<\/p>\n
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Schein’s Common Sense Emergency Abdominal Surgery<\/p>\n
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Management Options<\/p>\n
immediate operation (surgery now)<\/p>\n
pre-op prep and operation (surgery in am)<\/p>\n
conservative management<\/p>\n
discharge<\/p>\n
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Clinical Patterns<\/p>\n
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Abdominal Pain and Shock<\/p>\n
ruptured AAA ruptured ectopic<\/p>\n
(abdominal apoplexy)<\/p>\n
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also severe obstruction, acute mesenteric ischemia, and severe pancreatitis<\/p>\n
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Generalized Peritonitis<\/p>\n
umbilicus is the shallowest portion of the abdominal wall<\/p>\n
perforated ulcer, perforated colon, and perforated appendicitis<\/p>\n
always rule-out pancreatitis with a lipase, b\/c an operation in this case will do nobody any good.<\/p>\n
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Localized Peritonitis<\/p>\n
acute appendicitis<\/p>\n
acute cholecystitis<\/p>\n
acute diverticulitis<\/p>\n
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when the diagnosis is uncertain, the patients benefit from observation<\/p>\n
palpable mass in the rlq is a appendicieal phlegmon and surgery may not be indicated<\/p>\n
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Intestinal Obstruction<\/p>\n
the earlier and more severe the vomiting, the more proximal the obstruction<\/p>\n
vomiting and colicky pain are SBO<\/p>\n
constipation and gross distension are colonic<\/p>\n
simple adhesive sbo does not need an op<\/p>\n
pitfalls<\/p>\n
look for an incarcerated femoral hernia in obese females<\/p>\n
elderly patient with partial sbo which resolves and then returns with a tumor<\/p>\n
elderly lady with resolving sbo who comes back with gallstone ileus<\/p>\n
terminal ileum bezoar in patients with history of gastric surgery<\/p>\n
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medical causes<\/p>\n
inferior wall mi<\/p>\n
dka<\/p>\n
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Optimizing a Patient<\/p>\n
remember, anesthesia takes away the body’s compensation for shock<\/p>\n
make them have a reasonable urine output 1\/2 cc\/kg<\/p>\n
that being said, drowning patients leads to post-op misery<\/p>\n
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preop abx<\/p>\n
ther or prophylactic<\/p>\n
should already be in the bloodstream before the scalpel touches the belly<\/p>\n
bugs are consistent:<\/p>\n
endotoxin generating facultative anaerobes like e.coli<\/p>\n
and obligate anaerobes like b. fragilis<\/p>\n
give higher doses in the face of massive fluid resus<\/p>\n
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examine after anes. and before incising<\/p>\n
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incision of indecision<\/p>\n
if going in through old incision, try to start a few centimeters below and enter peritoneum through virgin abdomen<\/p>\n
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trauma lap<\/p>\n
long incision<\/p>\n
remove small bowel<\/p>\n
suck out blood (preferably with cell saver)<\/p>\n
pack four quads<\/p>\n
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if you release massive IAH, pt will decompensate. Pause, manually compress the aorta and let anesthesia catch-up<\/p>\n
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the peritoneum consists of two compartments<\/p>\n
supracolic<\/p>\n
infracolic<\/p>\n
divided by transverse (mesocolon)<\/p>\n
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Peritonitis<\/p>\n
primary peritonitis is caused by micro-organisms originating from a source outside of the abdomen<\/p>\n
strep from genital tract<\/p>\n
e. coli from blood<\/p>\n
staph from PD cath<\/p>\n
<\/p>\n
lap of on advanced cirrhotic is an autopsy in vivo<\/p>\n
secondary peritonits-from ruptured or inflamed abdominal viscus<\/p>\n
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Contamination-spillage of contents without inflammation<\/p>\n
Resectable Intra abd infection-<\/p>\n
non-resectable<\/p>\n
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Source control****<\/p>\n
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Anastomosis<\/p>\n
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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<\/p>\n
the single layer anastomosis is associated with the lowest incidence of stricture formation<\/p>\n
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<\/p>\n
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if you primarily anastomose swollen bowel,the anastomosis can fail when the edema resolves<\/p>\n
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Closure<\/p>\n
use non-absorbable-nylon or prolene<\/p>\n
or delayed-PDS or maxon<\/p>\n
monofilament<\/p>\n
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do not use rapidly absorbed material such as vicryl or dexon<\/p>\n
monofilament slides better and does not saw the tissue<\/p>\n
mass closure of abdomen is fine-take large bites at least 1 cm away with small bites and include the muscle<\/p>\n
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or close posterior and then anterior fascia with one running suture<\/p>\n
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can leave the subcutaneous tissue alone, no deadspace reduction necessary<\/p>\n
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if it looks all right, then it’s too tight!<\/p>\n
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pre-closure checklist<\/p>\n
hemostasis perfect<\/p>\n
source control<\/p>\n
peritoneal toilet<\/p>\n
anastamosis viable<\/p>\n
small bowel in place below transverse colon<\/p>\n
omentum placed between incision and intestine<\/p>\n
fascial defects are all closed<\/p>\n
drains in place<\/p>\n
feeding jejunosostomy if indicated<\/p>\n
should the abdomen actually be closed<\/p>\n
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while the abdomen is open, you control it; when it is closed, it controls you.<\/p>\n
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Fistuli<\/p>\n
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post-op infection<\/p>\n
look for the pneumonia–inside the abdomen<\/p>\n
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old folks do horribly with ileostomies<\/p>\n
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