1. Exploratory laparotomy. 2. Splenectomy with distal pancreatectomy. 3. Left nephrectomy. 4. Evacuation of the bladder with primary repair. FLUIDS: Include 8 units of packed red blood cells, 4 units of FFP, 1 pack of platelets, and 3-1/2 liters of saline SPECIMENS INCLUDE: 1. Bullet fragments sent to lab for law enforcement 2. Spleen sent permanent 3. Left kidney sent permanent WOUND CLASSIFICATION: III Fresh traumatic wound from clean source Gunshot wound to the left thoracoabdominal region. The patient was brought to the Operating Room for an emergency exploratory laparotomy.
The Blood bank was notified to prepare for trauma needing type O blood until the patient could be cross matched. Before the procedure began the patient expressed an urgency to urinate but could not, a foley was placed and urine and blood came out. DESCRIPTION OF SURGERY: The patient was brought to the Operating Room and placed in the supine position. A large laparotomy set was opened and prepared by the scrub, the suction units and liga sure were set up by the circulator a sternal saw and chest spreader were brought in and held if needed, the abdomen was then prepped and draped .
A large mid line incision was made. There was a significant amount of blood immediately upon entry into the abdomen. The abdomen was then packed fully with lap sponges. At this point, the patient became hypo tensive. The procedure was paused by anesthesia so the patient could receive blood and volume products. Once the patient returned to normal the packs were removed , beginning in the right upper corner, where no injury to the liver or stomach was seen, continuing down to the right lower section where the bowel and right colon appeared to be intact.
During the surgery the bladder increasingly swelled. The packs were removed from the left lower section and there was no evidence of injury to the colon. Attention returned to the left upper section, where the packs were removed and it was dicovered that he had a shattered spleen, which had been mobilized by the wound. The wound appeared to go through the pancreas. The splenic artery was identified and hemostasis was achieved by pressure while the kidney was dissected from the surrounding tissues. The splenic artery and vein were then clamped and ligated.
The hilum was then divided. The spleen and what appeared to be the tail end of the pancreas was passed off the field as specimen. When the specimen was removed a large hematoma was seen. Attention turned towards the bullet wound, which was explored. In the left abdominal wall a large wound with some exposure of the bone of a rib, but no evidence of diaphragm injury could be seen . Attention turned towards the hematoma, which had been followed and continued to expand. The left colon was then moved by identifying the white line of toldt and dividing the attachments.
The hematoma appeared to be isolated to the area around the kidney and did not track beyond the branching of the aorta. The ureter was easily identified after the colon was moved, the ureter was dilated and darkened,causing concern for blood in the ureter. It was at this point that a consult was called for Urology. The moving of the colon allowed visulazation of the bifurcation of the aorta, which was then tracked ligated and divided. The left renal vein was identified as it crossed the aorta. It was dissected and a vessel loop was then placed around it for control.
The now identified renal artery was also dissected. It was tied using 0 silk on either side of the area of concern and was sharply divided. The left renal vein was then divided and ligated. The peritoneal hematoma was then entered. The hematoma was suctioned as much as possible . The entire mass was then able to be removed from the surrounding tissue. The ureter was traced, double clipped proximally and distally and then divided. The kidney was then also passed off the field as specimen. The abdomen was then heavliy irrigated and checked for bleeding. The aorta was thoroughly examined.
There were no other vascular injury identified. Attention turned towards the bladder, which had expanded considerably. Sutures were placed on both sides of the bladder and the bladder was incised and entered. There was some urine, but a large blood clot was found in the bladder. This was manually removed and the bladder was then heavily irrigated. The bladder was then sutured close. The Foley placement was checked again for proper placement. The Foley catheter will need to be long-term due to repair of the bladder. Attention then turned to the abdominal space, which was again examined for any ongoing bleeding.
None was found. Prior to closure the drain tube was checked to be in good position. The abdominal incision was then closed primarily using #1 monocryl for the fascia sutures. The skin was then closed with staples. The wound was packed overnight with gauze. Dressings were then applied. Ref (Casey Maples, Alexanders surgical procedures, Fuller surgical technologyy, Thibodeau structure & function,Googlee for spelling and terminology) Post op care considerations RISK: All post splenectomy patients have an increased risk of overwhelming bacterial infection.
Certain factors however do influence the degree of risk: · Age: Younger patients have greater risk · Underlying disease: Risk with underlying immunodeficiency > thalassemia > sickle cell anemia > traumatic splenectomy · Time since splenectomy: Recent splenectomy has greater risk than many years post-operatively Individuals undergoing splenectomy should receive the age appropriate pneumococcal vaccine, H. influenza and quadrivalent meningococcal vaccine (the latter for those > 2 years of age) if possible up to three weeks prior to removal of the spleen to optimize the immune response.
When this is not feasible and for emergency splenectomy, vaccination should be initiated as soon as possible after the patient’s recuperation. ADDITIONAL RECOMMENDATIONS AND PRECAUTIONS · Stress to patients the limits of both vaccination and prophylactic antibiotics. · Be sure that patients understand the need for prompt medical evaluation for all febrile illnesses · Patients who do not have rapid access to medical care should be advised to develop resources for the local availability of appropriate antibiotics.
· Patients need to be aware of the increased risk posed by dog bites, and tick and mosquito bites in areas endemic for babesia and malaria respectively. The adult and pediatric infectious disease services remain available to assist with individualizing patient-specific issues. Ref (http://clinicalpharmacy. ucsf. edu) DEFINITIONS: Duodenum: is the first part of the small intestine Hematoma: A hematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue.
Perinephric: The connective and fatty tissue surrounding a kidney Hilum:part of an organ where structures such as blood vessels and nerves enter Thoracoabdominal:of, relating to, involving, or affecting the thorax and the abdomen White line of Toldt: It marks the site of the peritoneal reflection where the colon is attached to the posterolateral abdominal wall. It’s important in surgery because this line must be incised to mobilize the colon. (http://wiki. answers. com/Q/What_is_white_line_of_toldt#ixzz21SupMUCX).