Friday, May 14, 2004

The patient I mentioned earlier:
Late 20's man shot twice, once in right shoulder with bullet underneath the skin above his clavicle. The other one entered his back along the right psoas muscle and exited just below the left costal margin in the midclavicular line. Hypotensive but A&O. To the OR....

Colon injury at hepatic flexure: If tissue destruction is slight, primary repair is the treatment of choice. He had quite a bit of tissue destruction so I resected the area with intent to re-anastamose it. But as the Ginsu man says, "Wait...there's more!!"

Duodenal injury: Several options exist for repair. Primary repair with drainage, repair with duodenostomy tube, or duodenal exclusion. This involves oversewing the pylorus with an absorbable suture and constructing a gastrojenjunostomy. The rationale is that the suture will dissolve after the repair has healed. If severe a trauma Whipple may be required. I repaired the injury and placed a sump drain.

Vena cava injury: Since this was a zone 2 retroperitoneal penetrating injury, inspection of the hematoma was required. As a surgeon you hate any kind of bleeding, especially the kind you can hear. While distal control is achievable, proximal control this situation would be difficult, to say the least. Using spongesticks control was gained and the vein was simply repaired. Of course the patient was cold and coagulopathic so I sewed on a bag and went to the unit...

Later that night, after he was resuscitated, he began to bleed again. Re explored and found some mesenteric bleeders and a portal vein injury. What likely happened was that the portal vein had suffered some blast effect and only gave way when his pressure rose. New bag and back to the unit...

POD 3: Returned for re-exploration. No further bleeding. Revised the duodenotomy, placed a duodenostomy tube, a gastrostomy tube, a jejunostomy tube, an additional sump drain, and brought out the distal colon as a mucus fistula and created an ileostomy. Another new bag

POD 6: Back for attempted closure, tracheostomy, and removal of the bullet. Was able to get about a third of the way closed. Patient beginning to experience the "loss of domain" associated with an open abdomen.

Trauma is soooo much fun!!!

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