Monday, September 12, 2005

Buy that Man a Wheelbarrow.....
Haven't posted any pictures in awhile. 50-ish male admitted for back pain. His H&P actually said he was "sitting on his porch drinking as was his usual habit when he fell and hurt his back". I am asked to see him about a "hernia". He relates no signs or symptoms of incarceration and states it has been there for "a few months". I pull back the sheet and.....just say he made this guy look like an amateur.
Let's get a CT scan....

Not too bad right now.

Not a lot of bowel seen.....

Here is the defect. About 8cm from my measurement.

Oh my. He seems to have more bowel in his scrotum than in his abdomen proper. This, to put it mildly, presents a problem. Given the size of the hernia just "shoving everything back in" really won't work. His abdomen has "gotten used" to the bowel not being there and he has what is called a "loss of domain". If the hernia was repaired in the usual fashion the chances of abdominal compartment syndrome and respiratory failure would be very high. In newborns with gastroschisis the treatment with a "silo" which covers the bowel and is eventually "rolled in" a little at the time to allow the abdomen to stretch. In adults it is not so easy. Papers have appeared that some centers are using "therapeutic pneumoperitoneum" to expand the abdominal cavity enough to allow for reduction of the contents. Having never done this I sent this fellow off to the Ivory Tower, where they have done this once or twice.
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