Thursday, June 14, 2007

tricky gallbladder

An elective gallbladder yesterday that turned out to be a little complicated. Everything progressed well until I began my dissection in the distal infundibular area. I bluntly strip the peritoneum and fatty lymphatics off the cystic duct/infundibular interface using a Maryland dissector. First, there was an anterior cystic artery, intimately associated with the presumed cystic duct. I isolated this, identified it going up and arborizing on the gallbladder wall, and then clipped and cut it. The cystic duct, obviously terminating proximally in the infundibulum of the gallbladder, was very short and I could see it slightly tenting the common bile duct (CBD). I put a clip up on the proximal cystic duct and made a ductotomy with shears. I use the Ranfac cholangiocatheter for my cholangiograms, placed through a separate stab incision using a 14g angiocatheter. Unfortunately, the cystic duct was very narrow and fibrosed and I couldn't get the catheter introduced. In attempting to cut a little more, I actually transected the cystic duct. It was extremely thin and the lumen almost fibrosed. So I grasped the short stump and clipped it twice, being careful not to compromise the CBD. This released the gallbladder from its porta hepatis attachments and the infundibulum retracted nicely out of the way. Then i saw something I didn't like; another tubular structure emanating from the more proximal CBD that seemed to snake its way behind the gallbladder. I think my heart jumped into my pharynx at this point. Did I just cut a right hepatic duct? I completely liberated the gallbladder from its peritoneal attachments to the liver using cautery, essentially flopping it up over the anterior surface of the liver. This allowed me to dissect out where this thin structure wanted to go. It clearly did not connect to the gallbladder but, rather, inserted into the liver, just below the gallbladder fossa. I think this represented an accessory duct. A cholangiogram at this point would have involved doing a choledochotomy, which I felt was inadvisable. I simply left a drain in the RUQ and called it a day. Her liver function tests this morning are completely normal and the drain output is serous. So hopefully, I averted disaster.

Wednesday, June 13, 2007

My Cavs are about sunk. It would be nice if professional basketball players could knock down wide open jump shots. It's been their achilles heel all season. Nobody on the squad has a reliable J. Lebron gets triple teamed, passes to the open man and, time and again, Marshall or Jones or Sasha or Gibson clangs a brick. Must be frustrating as hell for the King. And we have no cap room to sign anyone of significance this summer. Marshall, Hughes, and Damon Jones (all signed in the summer of 2005 when we had a gazillion dollars in cap room) have all turned out to be complete busts. Danny Ferry (who killed our team when he was a player, i.e. the Ron Harper trade) seems to be looking to do the same thing as a GM. He needs to start taking some heat.

About a week ago I operated on a 85 yo lady for fulminant c difficile colitis. She had peritonitis, metabolic acidosis, the whole she-bang. Thankfully, she weighed maybe 95 pounds, so the proctocolectomy took about an hour and fifteen minutes. She had been doing reasonably well post op until yesterday morning when her skin looked very erythematous at about the midpoint of the wound. I was obviously concerned about a wound infection, so I removed a couple of staples only to encounter serosanguinous fluid and a loop of bowel poking out. She had a persistent ileus, and her albumin was 1.2, so dehiscence was not unexpected. (maybe I should have put retaining sutures in, but sometimes that's difficult with an ileostomy.) I took her to the OR because I was worried about her eviscerating in the ICU. The suture knot was intact, but her fascial edges were completely non-viable. The PDS had simply tore through the gummy fascia with the increased abdominal pressure from the ileus. So how do you close the abdomen? I actually used the biologic alternative Alloderm (an acellular dermal substitute) and sutured it circumferentially to the rectus sheath with running prolene. Voila, tension-free bridging of the gap. The only problem with Alloderm is that you have to wait at least 20 minutes for the damn stuff to sit in saline. It comes out of the package hard and chalky like drywall and you just have to wait for it to become fully saturated. That's a major problem, as far as I'm concerned. Sometimes you don't know what size you need until you're ready to use it, so you can't always start the soak business as you're prepping the patient. It's a pain in the ass, frankly. The other material out there is called Permacol. I used it as a resident. It's actually small intestinal submucosa from a pig. It comes out of the bag ready to use (albeit with a reeking odor) and it seems to work just as well. These new biologic alternatives to abdominal wall closure are a great resource, especially in contaminated cases.

Thursday, June 7, 2007

unusual cause of bowel obstruction

Very interesting case from over the weekend. This was a 65 year old guy I was called about on a Sunday. He started having crampy abdominal pain on the previous Thursday that seemed to progressively worsen as Friday dinner time rolled around. After picking at his plate, nausea ensued with multiple episodes of emesis. He finally came into the hospital Saturday morning, and after waiting 6 hrs in the ER waiting room, a CT scan suggested "small bowel thickening" and he was admitted to the hospitalist service. When I evaluated him, he clearly had diffuse peritoneal signs with a WBC count of 16k. My impression of the CT scan was that of a high grade small bowel obstruction with massive gastric dilatation. In the LUQ, there was a segment of SB with mural thickening and mesenteric inflammatory changes. Complicating matters, this man had been started on coumadin about a month ago for atrial fibrillation and his INR was 6.9. We placed a nasogastric tube and commenced IV fluid resuscitation with saline. I also quickly gave him 7 units of FFP to try and correct the coagulopathy. Ultimately, I took him for exploration later that day. Findings: 15 cm segment of indurated, hemorrhagic proximal jejunum with obvious hemorrhage into the mesentery. The SMA was palpable and strong. The rest of the bowel looked completely viable and healthy. I resected the involved segment and performed a hand sewn side to side anastomosis. The final path showed hemorrhagic transmural infarction of the bowel with gangrenous changes.

The question: what was the underlying etiology? It clearly wasn't mesenteric ischemia. His only previous abdominal surgery was a lap chole ten years prior, and there weren't any significant intra-abdominal adhesions. Then I did some digging on Pubmed re: bowel obstructions and anti-coagulation. I think he had a spontaneous transmural intestinal bleed that ultimately led to the ischemic changes. The guy is now post-op day 3 and he's making good progress. Will probably start clears tomorrow.