the thoughts of a surgeon in the notorious province of mpumalanga, south africa. comments on the private and state sector. but mostly my personal journey through surgery.
Thursday, November 01, 2007
what would you do?
this is a slight break from my usual style post, but a change is like a holiday.
so for the surgeons out there, what would you do with this case i saw recently?
I hate having to diagnose these things with only a single scan. But I see air anterior to the rectus muscle, and the muscle is thickened and the bowel immediately below it seems to be as well. Perhaps there's a richter's type hernia involving a prior defect, ie an incision somewhere, with rupture of the incarcerated knuckle of bowel.
Or, as the story goes, it's a "wind abscess." You drain them, there's a rush of air, and the patient dies.
i thought mentioning buckeye's post would give it away. he postd about whether to do primary anastomosis in the presence of diverticulitis. amazingly enough this is complicated diverticulitis.
this one i did drain. yes, a very low output fistula formed. i prepared the bowel and i went in. resection and primary anastomosis later and all's well that ends well.
sid, i agree, these single shots only give a very small idea of what's going on. in our radiology suite, the scans are on a computer where i can leisurely scroll up and down to see every millimeter of every part of him.
interesting case. Nice work avoiding colostomy. I'd worry about post op fasciitis in this kind of scenario (air/presumably pus and/or stool tracking through the abdominal wall). Did you make a separate LLQ incision over that air pocket and irrigate/debride? Was there erythema/induration over it? Initially, I too thought it was a spigelian.
buckeye, i staged it. first i drained the abses and left it open, under antibiotic cover. it formed a fistel. no surprise there. then i prepared his bowel. then, after about a week i did the definitive operation with primary anastomosis. i still left the abses wound open. it cleared up right after the operation, as could be expected.
this is a slight break from my usual style post, but a change is like a holiday.
Not sure what the current repair technique is, just wanted to know if I had the correct diagnosis--Spigelian hernia?
ReplyDeletegood call, but no. it is not a spigelian. note the lack of bowel wall between the air and the fat.
ReplyDeletea clue can be found in a very recent post of buckeye.
Okay, here goes my guess....retropertoneal rupture of the appendix resulting in subcutaneous emphysema?
ReplyDeleteOr, handle bar hernia?
If I'm close, I owe it to Google....
Please, no spelling critiques, I see it and now it is too late to correct. Argh!
ReplyDeleteI hate having to diagnose these things with only a single scan. But I see air anterior to the rectus muscle, and the muscle is thickened and the bowel immediately below it seems to be as well. Perhaps there's a richter's type hernia involving a prior defect, ie an incision somewhere, with rupture of the incarcerated knuckle of bowel.
ReplyDeleteOr, as the story goes, it's a "wind abscess." You drain them, there's a rush of air, and the patient dies.
i thought mentioning buckeye's post would give it away. he postd about whether to do primary anastomosis in the presence of diverticulitis. amazingly enough this is complicated diverticulitis.
ReplyDeletethis one i did drain. yes, a very low output fistula formed. i prepared the bowel and i went in. resection and primary anastomosis later and all's well that ends well.
sid, i agree, these single shots only give a very small idea of what's going on. in our radiology suite, the scans are on a computer where i can leisurely scroll up and down to see every millimeter of every part of him.
ReplyDeleteinteresting case. Nice work avoiding colostomy. I'd worry about post op fasciitis in this kind of scenario (air/presumably pus and/or stool tracking through the abdominal wall). Did you make a separate LLQ incision over that air pocket and irrigate/debride? Was there erythema/induration over it? Initially, I too thought it was a spigelian.
ReplyDeletebuckeye, i staged it. first i drained the abses and left it open, under antibiotic cover. it formed a fistel. no surprise there. then i prepared his bowel. then, after about a week i did the definitive operation with primary anastomosis. i still left the abses wound open. it cleared up right after the operation, as could be expected.
ReplyDeleteOkay, so I was along way off.....shouldn't try to run with the big dogs!
ReplyDeleteCan I blame a far miss on Google?