M & M M & M 05/06/0805/06/08

Lingxiang Ye, MDLingxiang Ye, MD

Dept. General SurgeryDept. General Surgery

Sinai HospitalSinai Hospital

HPIHPI 85 yo female85 yo female PMH: HTNPMH: HTN PSH: C-section, ventral hernia repair with PSH: C-section, ventral hernia repair with

small bowel resection 4 years agosmall bowel resection 4 years ago 04/11/08: Increasing abd pain, with N/V for 3 04/11/08: Increasing abd pain, with N/V for 3

days; no BM for 1 day; no fever or chilldays; no BM for 1 day; no fever or chill VS: T 35.9, P 85, BP 184/90, RR 22, SaOVS: T 35.9, P 85, BP 184/90, RR 22, SaO22

97% RA97% RA PE: Obese, mild distress, A A+O x 3PE: Obese, mild distress, A A+O x 3

HEENT: PERRLA; Resp: CTA B/L; Heart: RRRHEENT: PERRLA; Resp: CTA B/L; Heart: RRRAbd: large abd with large panniculus, a Abd: large abd with large panniculus, a midline incision scar, soft, NT, ND, (+) BS; midline incision scar, soft, NT, ND, (+) BS; swelling and tenderness in left inguinal areaswelling and tenderness in left inguinal area

HPIHPI

LabsLabs

CT of ABD: Dilated loops of small bowel CT of ABD: Dilated loops of small bowel around left inguinal area; distal small around left inguinal area; distal small bowel was collapsed; localized fluid bowel was collapsed; localized fluid collection in anterior abdominal wall collection in anterior abdominal wall (previous surgical area)(previous surgical area)

140

4.5

10125

15

1.05119 14.9

14.5

44.7

223

LFT: WNL

CT of Abdomen: 4/11/08

Hospital CourseHospital Course Diagnosis: small bowel obstruction secondary to incarcerated Diagnosis: small bowel obstruction secondary to incarcerated

left inguinal hernia, or possible due to recurrent ventral left inguinal hernia, or possible due to recurrent ventral hernia, or due to small bowel adhesionshernia, or due to small bowel adhesions

NPO, NTG, IVF resuscitation, ORNPO, NTG, IVF resuscitation, OR Intraoperative finding:Intraoperative finding:

There was a large indurated mass felt much higher above L There was a large indurated mass felt much higher above L inguinal area and toward midline incisioninguinal area and toward midline incision

The mass was actually the previous mesh with old hematoma. The mass was actually the previous mesh with old hematoma. There was massive adhesions of small bowel to the mesh and an There was massive adhesions of small bowel to the mesh and an internal hernia was found to cause the small bowel obstructioninternal hernia was found to cause the small bowel obstruction

There was a chronically incarcerated left inguinal hernia, which There was a chronically incarcerated left inguinal hernia, which was not the cause bowel obstructionwas not the cause bowel obstruction

Procedure:Procedure: Exploratory laparotomy, LOA, and release of small bowel Exploratory laparotomy, LOA, and release of small bowel

obstruction of internal hernia. Evacuation of old hematomaobstruction of internal hernia. Evacuation of old hematoma Repair of chronically incarcerated left inguinal hernia with Perfix Repair of chronically incarcerated left inguinal hernia with Perfix

mesh plugmesh plug 2 large Hemovac drains placed subcutaneously2 large Hemovac drains placed subcutaneously

Hospital CourseHospital Course POD 1 – 5: Doing well, AF, VSS, NGT, NPO, POD 1 – 5: Doing well, AF, VSS, NGT, NPO, POD 5: (+)BS, (+) flatus, (+) BM, minimal NGT output, NGT POD 5: (+)BS, (+) flatus, (+) BM, minimal NGT output, NGT

removedremoved POD 6: N/V; abd soft, NT, ND, (+) BSPOD 6: N/V; abd soft, NT, ND, (+) BS

NGT placement NGT placement POD 6-12:POD 6-12:

Increasing leucocytosis: WBC from 10,000 to 17,000Increasing leucocytosis: WBC from 10,000 to 17,000 CT (POD6): loop of bowel protruding to the abd wall in L lower CT (POD6): loop of bowel protruding to the abd wall in L lower

abdomen but not causing bowel obstruction; fluid collection with air in abdomen but not causing bowel obstruction; fluid collection with air in the anterior abdominal wallthe anterior abdominal wall

Abd X-rays (POD 8-12): distention of proximal and mid small bowel, Abd X-rays (POD 8-12): distention of proximal and mid small bowel, indicating small bowel obstructionindicating small bowel obstruction

AF, VSS, abd soft, NT, ND, (+) BS, (+) BM AF, VSS, abd soft, NT, ND, (+) BS, (+) BM NPO, NGT, IVFNPO, NGT, IVF

POD 13: POD 13: NGT was removed again,NGT was removed again, pt developed N/V, and NGT placed againpt developed N/V, and NGT placed again TPN initiated for nutrition supportTPN initiated for nutrition support

4/17 (POD 6): CT of abdomen 4/20 (POD 9): X-ray of abd

4/23 (POD 12): X-ray of abd

Hospital CourseHospital Course POD 13-16:POD 13-16:

AF, VSS; abd soft, NT, AF, VSS; abd soft, NT, CT of abd (POD 14): Loop of bowel within defect of CT of abd (POD 14): Loop of bowel within defect of

abd wall of left lower abdomen, distention of abd wall of left lower abdomen, distention of proximal small bowel and transition to proximal small bowel and transition to decompressed bowel; fluid collection with air in the decompressed bowel; fluid collection with air in the anterior abdominal wallanterior abdominal wall

Hospital CourseHospital Course POD 17- 21:POD 17- 21:

Fever with Tm 39.2Fever with Tm 39.2 Tachycardiac: P 100s – 120sTachycardiac: P 100s – 120s Erythema around PICC line. Picc line removed, Erythema around PICC line. Picc line removed,

Vanc/Zosyn covered.Vanc/Zosyn covered. Cr trending up to 4.1, and UOP trending down to 400 Cr trending up to 4.1, and UOP trending down to 400

ml/24 hoursml/24 hours Lactate 1.9 to 3.2Lactate 1.9 to 3.2

POD 22POD 22 Distressed, SOB, Tachy, Abd soft, NTDistressed, SOB, Tachy, Abd soft, NT ABG: 7.38/26/194/15/99%, lactate 2.4ABG: 7.38/26/194/15/99%, lactate 2.4 INR 2.3, APTT 60INR 2.3, APTT 60 Cr 5.8 Cr 5.8 Transferred to ICUTransferred to ICU

Hospital CourseHospital Course POD 23:POD 23:

Decompensated metabolic acidosis (pH 7.27, Decompensated metabolic acidosis (pH 7.27, bicarb 15, lactate 3.2)bicarb 15, lactate 3.2)

Anuric, Cr 6.9Anuric, Cr 6.9 Leucocytosis: WBC 18,000Leucocytosis: WBC 18,000 INR 2.8, APTT 61INR 2.8, APTT 61 PE: mild left side abd tenderness; (-) guarding, PE: mild left side abd tenderness; (-) guarding,

(-) rebound(-) rebound CT: No changed loculated fluid collection with CT: No changed loculated fluid collection with

air in the anterior abdominal wall; Loop of bowel air in the anterior abdominal wall; Loop of bowel protruding in the anterior left lower abdomenprotruding in the anterior left lower abdomen

5/4 (POD 24): CT of Abdomen

Hospital CourseHospital Course POD 23 (cont):POD 23 (cont):

Decision was made to explore the left hernia repair site to rule Decision was made to explore the left hernia repair site to rule out a strangulated segment of small bowel out a strangulated segment of small bowel

Intraoperative finding:Intraoperative finding: Went through left inguinal incisionWent through left inguinal incision There was a loop of bowel pushed up medially beyond the mesh There was a loop of bowel pushed up medially beyond the mesh

plugplug The loop of bowel was freed up, there was a small segment of bowel The loop of bowel was freed up, there was a small segment of bowel

with possible ischemia, which was resected with primary with possible ischemia, which was resected with primary anastomosisanastomosis

The small intestine was pushed backThe small intestine was pushed back Digital exploration of the abdominal cavity revealed no evidence of Digital exploration of the abdominal cavity revealed no evidence of

any serosanguinous fluid which would indicate necrotic intestine in any serosanguinous fluid which would indicate necrotic intestine in other portions of the abdominal cavityother portions of the abdominal cavity

Hernia repaired by bringing medial portion of the abdominal wall to Hernia repaired by bringing medial portion of the abdominal wall to Cooper’s ligamentCooper’s ligament

Transferred back to ICUTransferred back to ICU

Hospital CourseHospital Course Current statusCurrent status

Pressor to maintain BPPressor to maintain BP Intubation and ventilation for Intubation and ventilation for

respiratory failurerespiratory failure CRRT for ARFCRRT for ARF Bicarb gtt for metabolic acidosisBicarb gtt for metabolic acidosis Linezolid, zosyn, diflucan for sepsisLinezolid, zosyn, diflucan for sepsis FFP for coagulopathyFFP for coagulopathy

ComplicationComplication

Multiple organ failure due to Multiple organ failure due to delayed reexploration of small bowel delayed reexploration of small bowel obstruction?obstruction?