#Case_23 - Internal - Mesenteric defect - Hernia!

[DrAmir0078]

Hi SDN Anesthesiologists,
Today case is :
Term parturient presented for elective cesarean section and 15 years ago had Appendectomy, the OB told me, she only had vomiting for the last three days and had visited private clinics a surgeon and internist and had investigation including ultrasound and both agreed on irritable bowel syndrome (gave her treatment).
I myself saw the patient, tired and with mild dehydration, and she mentioned no bowel motion and no flatus for the last 3 days, and I insisted if that was true, she said yes.
I refused to proceed to anesthesia, until I got a new consult from the government hospital for medicolegal documentation and to be seen by internist or surgeon. She went to nearby hospital and got ultrasound and medical consult, the ultrasound report mentioned sluggish bowel movements and distended proximal bowel and normal distal bowel with no free fluids, and everything else was normal... Etc
I asked the OB, such constipation is it common? She said yes. Are you OK with it? She said yes. Myself I felt something wrong of possible intestinal obstruction.

I gave RSI with Esmeron, no scoline, had 1 Ringer is running fast and done, and the 2nd started, tube in, OB fast, opening peritoneum, blood came out - hemoperitoneum - some small intestine looks hyperemic. Baby safe out, suturing done for uterus, leak of blood somewhere, I had finished my 3rd fluid. Surgeon 30 minutes to arrive, he made another mid line incision, internal hernia found, loop of small intestine was like strangulated in a defect in the mesentery, release done, no bowel cut, color return slowly, hoping not gangrenous. Laxis given. Good urine output. Blood 1 unit given. NG tube in. Got good pain control. Extubated smoothly.Another fluid given. Total 2 Lt of fluids + 1 unit of blood. She was hemodynamically stable. Operation time around 2 hours.


Lesson here: Do not miss detailed history taking. Vomiting could be something serious!

I didn't spinal here for my suspicion of taking longer Op time and she was so anxious.

How many times to see such hernia!

Cheers and Peace.

P. S. The photo taken and edited by me, you may see the defect hole filled with surgical pack to hemostasis the defect before closing it.

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[dabears505]

Nice

 

[coffeebythelake]

Hi SDN Anesthesiologists,
Today case is :
Term parturient presented for elective cesarean section and 15 years ago had Appendectomy, the OB told me, she only had vomiting for the last three days and had visited private clinics a surgeon and internist and had investigation including ultrasound and both agreed on irritable bowel syndrome (gave her treatment).
I myself saw the patient, tired and with mild dehydration, and she mentioned no bowel motion and no flatus for the last 3 days, and I insisted if that was true, she said yes.
I refused to proceed to anesthesia, until I got a new consult from the government hospital for medicolegal documentation and to be seen by internist or surgeon. She went to nearby hospital and got ultrasound and medical consult, the ultrasound report mentioned sluggish bowel movements and distended proximal bowel and normal distal bowel with no free fluids, and everything else was normal... Etc
I asked the OB, such constipation is it common? She said yes. Are you OK with it? She said yes. Myself I felt something wrong of possible intestinal obstruction.

I gave RSI with Esmeron, no scoline, had 1 Ringer is running fast and done, and the 2nd started, tube in, OB fast, opening peritoneum, blood came out - hemoperitoneum - some small intestine looks hyperemic. Baby safe out, suturing done for uterus, leak of blood somewhere, I had finished my 3rd fluid. Surgeon 30 minutes to arrive, he made another mid line incision, internal hernia found, loop of small intestine was like strangulated in a defect in the mesentery, release done, no bowel cut, color return slowly, hoping not gangrenous. Laxis given. Good urine output. Blood 1 unit given. NG tube in. Got good pain control. Extubated smoothly.Another fluid given. Total 2 Lt of fluids + 1 unit of blood. She was hemodynamically stable. Operation time around 2 hours.


Lesson here: Do not miss detailed history taking. Vomiting could be something serious!

I didn't spinal here for my suspicion of taking longer Op time and she was so anxious.

How many times to see such hernia!

Cheers and Peace.

P. S. The photo taken and edited by me, you may see the defect hole filled with surgical pack to hemostasis the defect before closing it. View attachment 375206

Strong work and nice instincts.

 

[MirrorTodd]

Well done I'd say Dr Amir. Ultimately, the other hospital should've probably got a ct scan or MRI if those were available. CT's in term pregnancy as far as I know have not proven to increase cancer risk.

 

[DrAmir0078]

Well done I'd say Dr Amir. Ultimately, the other hospital should've probably got a ct scan or MRI if those were available. CT's in term pregnancy as far as I know have not proven to increase cancer risk.

Very true, although it is a district general hospital, but fortunately they have a CT device - I have no idea why they didn't order a study for her (either it was out of order or doctor decision). The family were understanding the situation and the same time blaming all doctors they visited them and they didn't diagnosed their patient right.

Sent from my SM-G950F using SDN mobile

 

[vector2]

Hi SDN Anesthesiologists,
Today case is :
Term parturient presented for elective cesarean section and 15 years ago had Appendectomy, the OB told me, she only had vomiting for the last three days and had visited private clinics a surgeon and internist and had investigation including ultrasound and both agreed on irritable bowel syndrome (gave her treatment).
I myself saw the patient, tired and with mild dehydration, and she mentioned no bowel motion and no flatus for the last 3 days, and I insisted if that was true, she said yes.
I refused to proceed to anesthesia, until I got a new consult from the government hospital for medicolegal documentation and to be seen by internist or surgeon. She went to nearby hospital and got ultrasound and medical consult, the ultrasound report mentioned sluggish bowel movements and distended proximal bowel and normal distal bowel with no free fluids, and everything else was normal... Etc
I asked the OB, such constipation is it common? She said yes. Are you OK with it? She said yes. Myself I felt something wrong of possible intestinal obstruction.

I gave RSI with Esmeron, no scoline, had 1 Ringer is running fast and done, and the 2nd started, tube in, OB fast, opening peritoneum, blood came out - hemoperitoneum - some small intestine looks hyperemic. Baby safe out, suturing done for uterus, leak of blood somewhere, I had finished my 3rd fluid. Surgeon 30 minutes to arrive, he made another mid line incision, internal hernia found, loop of small intestine was like strangulated in a defect in the mesentery, release done, no bowel cut, color return slowly, hoping not gangrenous. Laxis given. Good urine output. Blood 1 unit given. NG tube in. Got good pain control. Extubated smoothly.Another fluid given. Total 2 Lt of fluids + 1 unit of blood. She was hemodynamically stable. Operation time around 2 hours.


Lesson here: Do not miss detailed history taking. Vomiting could be something serious!

I didn't spinal here for my suspicion of taking longer Op time and she was so anxious.

How many times to see such hernia!

Cheers and Peace.

P. S. The photo taken and edited by me, you may see the defect hole filled with surgical pack to hemostasis the defect before closing it. View attachment 375206

Nice case, Amir. All I would offer is that if you had a very high suspicion of obstruction pre-op, placing an NG tube before induction is usually wise. Also, gastric ultrasound to look at the antrum volume can be helpful in these situations too (even in parturients).

 

[DrAmir0078]

Nice case, Amir. All I would offer is that if you had a very high suspicion of obstruction pre-op, placing an NG tube before induction is usually wise. Also, gastric ultrasound to look at the antrum volume can be helpful in these situations too (even in parturients).

Thank you so much for bringing up this concern and a pretty trick that I have no clue about it - using ultrasound.
So the concern here is placing NG tube before or after the intubation. It has been a debate. Some said they rather place an NG after the induction because of fearing that placing the NG will open the cardiac sphincter (GES) and would risk the aspiration while induction of anesthesia even with RSI as gravid uterus or even if true obstruction with Distended abdomen will increase the intra-abdominal pressure and would push gartic content up much easier if the NG in place as the GES is opened - jeopardize its opening!
Other said it is wiser to insert NG tube and aspirate as much as you could and then induce.
Regardless of both, there were a debate regarding patient position either head side bed up or down. Moreover patient discomfort when placing NG.
Pregnancy itself should be considered full stomach. I myself watch carefully preoxygenate, had the patient to go deep, if I need more time, would self bag Ventilate not using ventilator and watch the peak Pressure not to reach 20 cm h2o fearing such pressure would open the GES.
So, I would place you with the school of inserting NG prior, which is again right. Finally, both scenario should be treated with antacid prior to ETT.