PREOPERATIVE DIAGNOSIS: Small bowel obstruction.
POSTOPERATIVE DIAGNOSIS: Small bowel obstruction.
1. Exploratory laparotomy.
2. Decompressive enterotomy.
3. Evacuation of bezoar.
FINDINGS: The patient had a proximal jejunal obstruction with a dilated proximal jejunum secondary to what appeared to be a bezoar of undigested food. The patient had a nasogastric tube in his stomach that was palpable. The patient, from ligament of Treitz down to the first 3 feet of intestine, was dilated and filled with a thick succus material. From that point on distally, the small bowel was of normal caliper and size. The right colon was normal. The transverse colon was normal. The descending colon was normal. The sigmoid colon was normal with the exception of some diverticulosis. There was no evidence of diverticulitis. The stomach palpated was normal. Both right and left hepatic lobes were palpable and normal. There were no adhesions in the abdomen. The only significant finding was this dilated small intestine secondary to what appeared to be a bezoar of undigested food.
SPONGE AND INSTRUMENT COUNT: Sponge, needle and instrument counts were correct at the end of the case.
ESTIMATED BLOOD LOSS: Less than 50 mL.
INDICATIONS FOR PROCEDURE: a 60-year-old gentleman who presented to the emergency room, with complaints of abdominal pain, nausea, and vomiting. The patient was admitted to the hospital last evening by Dr. The patient had a nasogastric tube inserted in the stomach. The patient was taken to radiology where a CT scan was obtained. The CT scan demonstrated a high-grade obstruction of the mid jejunum. The general surgery service was then consulted. The patient was examined and found to have a soft abdomen without bowel sounds. He had significant output from a nasogastric tube. The patient had been ill for the last week and a half. There had been no improvement in his symptoms. Given the findings on CT scan and examination the patient was consulted for exploratory laparotomy for possible small bowel obstruction.
DESCRIPTION OF PROCEDURE: After consent was obtained, the procedure risks and benefits described at length, the patient was taken to the operating room and placed supine on the operating room table. The patient had received Levaquin and Flagyl preoperatively. PAS stockings were applied to both lower extremities. The patient was then placed under general endotracheal anesthesia. The patient?s abdomen was prepped and draped in a standard surgical fashion.
A midline laparotomy incision was made from about 4 fingerbreadths below the xiphoid to just below the umbilicus. The abdomen was opened. There was no fluid upon expiration. The exploration of the abdominal cavity demonstrated distended small intestine from the mid jejunum proximally to the ligament of Treitz. The small bowel was then run from the ligament of Treitz all the way to the ileocecal valve. The mid jejunum was dilated with what appeared to be a thickened succus undigested food and no mass was palpated. The distal small bowel was all completely normal. The mesentery was also normal. There was no evidence of adenopathy. The right colon was palpated and normal. The transverse colon was palpated and was normal. The descending colon was palpated and normal. The sigmoid colon was palpated. No masses were identified but there was some significant diverticulosis. The stomach was palpated and nasogastric tube in the stomach was retracted gently to just inside the stomach and not in the proximal duodenum. The right and left hepatic lobes were palpated and were normal.
The 2 bowel clamps were then placed in the proximal small bowel just past the ligament of Treitz and then just distal to the point of distention. Two stay sutures of 3-0 GIA silk were placed on the antimesenteric side of the bowel, and a longitudinal incision was made in the small bowel for approximately 2 cm. The contents of the small bowel causing obstruction were then milked gently out through the small bowel enterotomy. This was milked on to a 10 by 10 drape, which had been on the field and into the bucket. Significant effort was made to prevent any spillage of enteric contents onto the abdominal wall or into the wound.
When the small bowel had been completely evacuated at this area of distention, the enterotomy was closed. The enterotomy was closed in a transverse fashion using a 3-0 PDS suture with full-thickness bites. The suture was run to the midline and then a second one was run to the midline and then tied in the middle. The 3-0 GIA silks were then used in a Lembert fashion to cover the suture line. The bowel clamps were removed. The fluid was milked past the anastomosis and no leakage was noted. The small bowel that had now decompressed and evacuated was then palpated carefully throughout the ligament of Treitz down to the ileocecal valve, and no evidence of intraluminal masses or polyps were identified. There was no other etiology for the obstruction identified with the exception of this undigested food bezoar. The abdomen was again explored and no other pathology was identified.
The abdomen was then irrigated with 4 liters of normal saline. The abdominal incision was then closed. The fascial layer was closed with a #1 looped PDS x2. The skin was closed with surgical staples. A sterile dressing was applied.
The patient was awakened from anesthesia and taken to recovery room in stable condition. Sponge, needle and instrument counts were correct at the end of the case. Blood loss was less than 50 mL.