Saturday, July 08, 2006

lots of reeeealy big words

I came across this pathology report while going through my desk, and just thought I would share. Honestly I find this utterly fascinating, although it may have to do with the fact that someone had to write up a journey through my insides. This was, after all, exploratory surgery after I had been in the hospital over 24 hours experiencing sever pain and vomiting.

Ah, good times.

Warning, the document below is not for the weak of stomach.

Date of operation: 02/06/2004

Preoperative Diagnosis: Small Bowel Obstruction; Possible Crohn’s Disease

Postoperative Diagnosis: Small Bowel Obstruction Due to Adhesions

The patient had approximately 1 liter to 1.5 liters of clear slightly yellow tinged ascites. The small bowel was dilated and distended and the walls slightly thickened. The terminal ileal area which had previously been the site of a ileocolecomy many years earlier for Crohn’s Disease was a glomerulus of distal bowel wrapped around the anastomosis. Once this was taken down there was no thickening of tissues and we could palpate the open anastomosis to the colon easily. No other pathology was noted.

With the patient under satisfactory general anesthesia in supine position with air compression stockings on the leg and a Foley in the bladder and an NG tube to decompress the stomach the patient was prepped and draped in the usual sterile fashion.

The previously widened midline infraumbilical scar was excised and the incision taken down through subcutaneous tissues to the fascia. Minor bleeding points were electro coagulated. The fascia was entered carefully, the properitoneal space opened with scissors and immediately there was the gush of fluid which was suctioned free. The peritoneal incision was opened the full length of the incision from just above the pubis to the umbilicus and further ascites was suctioned clear.

We manipulated the small bowel and worked our way toward the right lower quadrant which was presumed to be the site of the obstruction and we lysed many adhesions between loops of bowel to free up the bowel in order to gain entrance into the right lower quadrant. We continued with tedious dissection and came across the glomerulus of small bowel wrapped around the area of the previous anastomosis and we were able to free this up without entering the bowel.

Once we had freed this up we saw clear evidence that the fluid and gas in the distal ileum could be easily milked into the colon and we were ale to palpate an approximately 1.5 cm to 2 cm anastomosis and there was no evidence of tissue thickening, crawling fat or any evidence of Crohn’s Disease in the abdomen. The bowel was now freed more proximally to make sure that everything was wide open which it was.

The irrigation was performed, minor bleeding points were electro coagulated, the bowel was placed back into the anatomical position and the omentum brought down over this. The gallbladder had no stones, the pylorus and liver were normal and the NG tube was placed appropriately in the stomach. The abdomen was now closed protectin the intra-abdominal contents with two double stranded heavy nylons running from the top and from the bottom and meeting and tied to themselves in the middle.

Copious irrigation of the subcutaneous tissue was performed and the subcutaneous tissues were approximated with multiple interrupted sutures of 3-0 plain catgut. The skin was now approximated with clips, dry dressings were applied and the patient was awakened, extubated and brought to the Recovery Room in satisfactory condition.

Neat huh?

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