Laparotomy

Ans. is d i.e. Stage III C

Ans. is b i.e. Krukenberg tumour

This is the classic presentation of Krukenberg tumour. For details, on Krukenberg tumour, see answer 45

Minilaparotomy

Ectopic pregnancy

This patient has a presentation and findings that are most consistent with a benign cystic teratoma. Dermoids are a type of ovarian germ cell tumor. Germ cell tumors are the most common type of ovarian neoplasm in females under the age of 20 and dermoids are the most common benign ovarian neoplasm.Dermoids can range in size from small masses that are noted ncidentally on ultrasound and cause no symptoms, to large cysts that cause pain and pressure, as this patient has. Laparotomy is the most appropriate next step in the management of this patient because, as adnexal masses enlarge–especially when they become greater than 5 cm–the risk of ovarian torsion increases. Thus, laparotomy withremoval of the dermoid is indicated to prevent torsion. Also, this patient’s mass is causing her symptoms of pain and pressure and, on that basis, should be removeD. Finally, while the mass most likely is a dermoid, this is not certain without pathologic diagnosis and, therefore, the cyst should be removed and evaluated by a pathologist. At the time of surgery, close examination should be made of the other ovary because dermoids may be found bilaterally in more than 10% of cases. To repeat pelvic examination in 1 year (Choice A)would not be correct management. This patient is symptomatic with a 6 cm ovarian mass that is at risk for torsion. She should, therefore, be managed surgically. To repeat pelvic ultrasound in 6 weekschoice B. is appropriate for some adnexal masses. For example, in a young woman with a small complex cyst that appears consistent with a corpus luteum, it may be most prudent to recheck an ultrasound in 6 weeks to see if the cyst has resolveD. This patient, however, is symptomatic with a 6 cm cyst that appears to be adermoid, which will not resolve spontaneously. She, therefore, requires surgery. To prescribe the oral contraceptive pill (Choice C) may help to prevent future ovarian cysts but it will not resolve this cyst, which requires surgical management.

Conservative laparoscopic treatment of ectopic pregnancy is now commonplace, although not  yet  universal.  With  increasing sophistication of  techniques and  fiberoptics,  many  microsurgical procedures can be done through the laparoscope Recent studies uggest that the fertility rates for laparoscopy and laparo- tomy are comparable, as are the implications of repeat ectopic pregnancies. Certainly laparoscopy, because of its small incision, results in fewer break- downs and shorter hospital stays, but the incidence of complications due to retained ectopic tissue is higher.

Exploratory laparotomy The presence of secondary pancreatic infection suspected in patients whose systemic inflammatory response (fever, WBC count or organ dysfunction) fails to resolve, CT-guided aspiration of fluid from pancreatic bed for performance of Gram’s stain & culture analysis is of critical importance. A positive is Gram’s stain or culture or identification of gas within pancreas on CT-scan, mandate operative intervention.

Failure to recbgnize adrenal cortical insufficiency, particularly in the ppstoperative patient, may be a fatal error that is especially regrettable because therapy (exogenous steroids)  is   effective   and   easy  to   administer. Adrenal insufficiency may occur in a host of settings including tuberculosis (formerly the most common cause), autoimmune state, severe infections (classically, meningococcal septicemia), pituitary insufficiency, after burns, during anticoagulant therapy, and—most commonly today—aft€r interruption of chronically administered exogenous steroids. Although the adrenal gland is an occasion3l site for distant metastases, such as from lung or breast, it is rare for there to be enough destruction of the glands to produce clinical adrenal insufficiency Chronic adrenal insufficiency (classic Addison’s diease) should be recognizable preoperatively by the constellation of skin hyponatremia, and hyperkalemia. Death  may occur  within hours of surgery if a patient with Addison’s disease is operated on without cognizance of adreria! insufficiency and pretreatment with exogenous steroids. Patients who have adrenal insufficiency as a result of interruption of chronically administered exogenous steroids may not develop the classic electrolyte abnormalities until the preterminal period. Adrenal insufficiency may also develop insidiously in the postoperative period, progressing over a course of several days. This insidious course is seen when adrenal injury occurs in the perioperative period, as  would  be  the  case  with adrenal damage from hemorrhage into the  gland in a   patient  receiving  postoperative  anticoagulant PTT. therapy Measurement of blood corticosteroid levels, urinary corticosteroid secretion, urinary sodium levels, and response to exogenous steroids is helpful in establishing the diagnosis of adrenal insufficiency pigmentation, weakness, weight loss, hypotension, nausea, vomiting, abdominal pain, hypoglycemia,

Always rnidline incision [Ref: Schwartz 9/e p160 (8/e, p160)] Repeat from All India 07

All emergency abdominal explorations in adults are performed using a long midline incision because of its versatility. For children under the age of 6, a transverse incision may be advantageous.

Ans. is a i.e. Immediate laparotomy

Also Know :

Even in those cases where there is doubt of ruptured ectopic pregnancy – Laparotomy should be done to “open and see”

“Immediate laparotomy and clamping of the bleeding vessels may be the only means of saving the life of a moribund ^patient”.

The only depolarizing type of neuromuscular blocker in clinical use is succinylcholine (SCh).

Gallamine is one of a series of synthetic substitutes for curare.

Gallamine has the most potent vagolytic properties of any relaxant, and it is entirely dependent on renal function for elimination.

In renal insufficiency the neuromuscular blockade that it causes is considerably prolonged and gallamine is contraindicated.

Here the Gravimetric method gives the best estimation of blood loss.

The weights of the swabs after use are subtracted from the dry weight of the swabs and this is added to the volume of blood collected in the suction bottles and/or drains.

Ref: Bailey and Love, 24th Edition, Page 61.

Laparotomy by midline incision is the “gold standard” therapy for intra-abdominal injuries.

It is definitive, rarely misses an injury, and allows for complete evaluation of the abdomen and retroperitoneum.

All patients with hypotension, abdominal wall disruption, or peritonitis need surgical exploration.

In addition, the presence of extraluminal, intra-abdominal, or retroperitoneal air on plain radiograph or CT should prompt surgical exploration.

Ref: Scalea T.M., Boswell S.A., Baron B.J., Ma O.J. (2011). Chapter 260. Abdominal Trauma. In J.E. Tintinalli, J.S. Stapczynski, D.M. Cline, O.J. Ma, R.K. Cydulka, G.D. Meckler (Eds), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e.

Most patients developed transient ileus after a major abdominal operation.

Most of these resolve within 3 to 5 days.

• The essence of treatment is prevention, with the use of nasogastric suction and restriction of oral intake until bowel sounds and passage of flatus return.
• Electrolyte abnormality, if any is corrected.
• A battery of laboratory tests are conducted to look for primary causes. which, if found is treated.
• “If paralytic ileus is prolonged and threatens life, a laparotomy should be considered to exclude a hidden cause and facilitate bowel decompression”

Patient in the question is showing features of disseminated intravascular coagulation secondary to sepsis caused by acute cholecystitis. Next best step in the management of patients coagulopathy, is to remove the foci of infection by doing an exploratory laparotomy.

The morbidity and mortality associated with DIC are primarily related to the underlying disease rather than the complications of the DIC. The control or elimination of the underlying cause should be the primary concern. Management of DIC involves, administration of fresh frozen plasma to replace the coagulation factors, cryoprecipitate to replace the low fibrinogen levels.

Ref: Harrison’s Internal Medicine, 18th Edition, Chapter 116

Ans. is ‘a’ i.e., Sub hepatic 

Ans is ‘b’ ie leave it as such 

“A wide-mouthed, thin walled unattached diverticulum in an adult patient can probably quite safely be left alone.”

– Maingot’s

• Treatment
• Any symptomatic Meckel’s diverticula is resected (Diverticulectomy)
• There are two techniques for excision of the diverticulum

–  simple excision resection with the segment of ileum containing the diverticulum and then reanastomosis.

• Resection of ileum with reanastomosis is reserved for patients with peptic ulceration in the ileal mucosa a gangrenous diverticulitis affecting the base of the diverticulum if the base of the diverticulum is inflamed or perforated in rare cases of malignant disease situated in Meckel’s diverticulum.
• Management of asymptomatic Meckel’s diverticula found incidentally on laprotomy
• Management is controversial and different books write differently.
• According to Maingot’s

– a wide-mouthed, thin walled Meckel’s diverticulum without any attached band can be left.

– prophylactic diverticulectomy is done – if the diverticula has a narrow base if there is any palpable thickening or adhesions suggestive of ectopic tissue.

– if there is any attachment either by bands to the umbilicus or by a mesodiverticular vascular strand.

Ans: ‘b’ i.e. Start IVF; ‘c’ i.e. Do Urgent laprotomy 

• This is a case of wound dehiscence (Burst abdomen)
• Serous or serosanguinous discharge from the wound is the_.first sign of dehiscence.Local Risk factors
• Although wound dehiscence may occur at any time following wound closure, it is most commonly observed between the fifth and eigth postoperative day.
• Wound dehiscence is partial or total disruption of any or all layers of the operative wound. Extrusion of abdominal viscera after rupture of all layers is known as evisceration
• Factors predisposing wound dehiscence

1)       Inadequate closure-most imp.

2)       Increased intraabdominal pressure

3)       Deficient wound healing – d/t infections, seromas, hematomas or presence of drain.

• Systemic Risk factors

–        Old age, obesity, systemic diseases (diabetes, uremia, jaundice, sepsis, cancer), immunosuppression increase the risk.

• Management
• For wound dehiscence without evisceration

– prompt elective reclosure of wound.

• For dehiscence with evisceration

– wound is covered with moist towels with the pt. under general anaesthesia, any exposed bowel or omentum is rinsed with lactated Ringer’s solution containing antibiotics and then returned to the abdomen. the previous sutures are removed and the wound reclosed.

Ans. is ‘b’ i.e., Intestinal obstruction 

Ans. is ‘a’ i.e., Immediate laparotomy 

This patient is not responding to IV crystalloids is likely to have a continuous source of bleeding. His abdomen is evaluated by an ultrasound (if available in the emergency department) or by diagnostic peritoneal lavage (DPL), to rule out intrabdominal injuries as the source of blood loss & hypotension.

If ultrasound or DPL are positive, then immediate laparotomy is done.

Ans is ‘d’ (Hemostasis)

Damage control surgery

• Is one of the major advances in surgical practice in the last 20 yrs in the management of trauma.
• It defers the traditional surgical teaching that, the first chance of any surgical intervention is the best chance for any definitive repair or reconstruction with good result.
• The conventional method of management of trauma patients was to bring the patients to the operating room after initial resuscitation, and to operate for complete repair of the injuries. Even patients with multiple complex injuries were operated aggressively over a prolonged period of time for definitive primary repair. Subsequently these patients were sent to the ICU where a good number of them died due to metabolic derangements.
• Recognising that the cause of death in the major trauma victims was not due to failure of the initial surgery, but due to metabolic derangements or the physiological alterations in the body following severe exsanguinating polytrauma, a new method of management evolved k/a Damage Control Surgery or Staged Laprotomy.

In Damage control surgery, there are 3 phase:

1st Phase – only abbreviated laprotomy is done for life saving measure, then in

find phase – pt. is sent to ICU for the correction of metabolic disorders

III phase – following satisfactory correction of metabolic disorders, the patient is brought again to the operating room – this time for planned definitive surgery.

Abbreviated laparotomy

• In abbreviated laparotomy life saving procedures are performed very rapidly.
• Temporary quick-fix procedures are used limited to conspicuous lesions.
• Control of hemorrhage is the top priority

– by quickly clamping and ligating the major vessels.

– gauze packing for major liver or retroperitoneal injuries.

• Contamination from damaged GI tract is managed quickly by ligating / stapling or simple running suture of the bowel.
• No attempt is made for complex repair at this stage.
• Tension free temporary closure of the abdomen is done with the help of towel clips (Silo or Bogota bags or vaccum pack) to avoid abdominal compartment syndrome

Ans is a i.e. Coagulopathy 

In critically injured patients, triad of hypothermia, acidosis, and coagulopathy is a vicious cycle that if uninterrupted, is rapidly fatal. Abbreviated laparotomy is utilized to quickly achieve hemostasis.

Patients are then transported to the surgical ICU for vigorous correction of metabolic derangements and coagulopathies.

Ans is A(Arrest hemorrhage), B(Prevent Coagulopathy) & C(Control contamination) 

Answer is C (Partial Gastrectomy + Distal pancreatectomy)

Partial gastrectomy with distal pancreatectomy should be adequate to manage this distal gastric tumor with direct invasion into the distal pancreas.

Tumors of the distal third / antrum of stomach require a subtotal gastrectomy (Partial gastrectomy). The distal pancreas should be removed as there is direct invasion of the distal pancreas. Splenectomy is not indicated as the tumor does not directly invade the spleen, and involvement of splenic hilar lymph nodes is unlikely as the tumor is located in the distal third of the stomach (and not in the proximal stomach). This patient is best managed by subtotal gastrectomy + lymphadenectomy + distal pancreatectomy.

Guidelines for management of Gastric carcinoma

• Surgical resection remains the mainstay of treatment of gastric cancer either for cure or for palliation
• The extent of gastric resection depends on the site of tumor in the stomach.

Tumors in the distal third or antrum of stomach require a subtotal gastrectomy (partial gastrectomy) while tumors of the middle or proximal third of the stomach require a total gastrectomy

Distal Third /Antrurn Gastric cancer                                        Middle Third /Proximal Gastric cancer

Subtotal Gastrectomv                                                        Total Gastrectomy

• The extent of resection of adjacent structures (pancreas, spleen etc) depends on the location of primary tumor and local invasion

Pancreatic Resection

The distal pancreas should not be removed a part of a resection for a cancer of the distal two third of the stomach (unless there is direct invasion)

The distal pancreas should be removed only when there is direct invasion and still a chance of a curative procedure in patients with carcinoma of the proximal stomach

Splenic resection

Splenectomy is not indicated unless the tumor directly invades the spleen or involves the splenic hilar lymph nodes. Resection of spleen and splenic hilar lymph nodes may be considered in patients with tumors of the proximal stomach located in the greater curvature / posterior wall of the stomach close to the splenic hilum where the incidence of splenic hilar nodal involvement is likely to be high.

Organ marked in the picture above represents uterus.

Complication of suction & evacuation (S&E) and management

• Diagnostic laparoscopy is often helpful to assess the size and site of perforation & the amount of haemorhhage.
• If perforation has occurred prior to complete evacuation & if laparotomy is decided, then complete the evacuation either through the rent or anterior hysterotomy, if preservation of uterus is necessary.
• Laparotomy is often needed to tackle the perforation. It also gives an opportunity to inspect intestine or omentum for evidence of injury
• If perforation has occurred prior to complete evacuation & family is completed, then hysterectomy can be done.

The structure marked by an arrow in the picture above represents Meckel’s diverticulum.

“A wide-mouthed, thin walled unattached diverticulum in an adult patient can probably quite safely be left alone.”

– Maingot’s

• Treatment
• Any symptomatic Meckel’s diverticula is resected (Diverticulectomy)
• There are two techniques for excision of the diverticulum

–  simple excision resection with the segment of ileum containing the diverticulum and then reanastomosis.

• Resection of ileum with reanastomosis is reserved for patients with peptic ulceration in the ileal mucosa a gangrenous diverticulitis affecting the base of the diverticulum if the base of the diverticulum is inflamed or perforated in rare cases of malignant disease situated in Meckel’s diverticulum.
• Management of asymptomatic Meckel’s diverticula found incidentally on laprotomy
• Management is controversial and different books write differently.
• According to Maingot’s

– a wide-mouthed, thin walled Meckel’s diverticulum without any attached band can be left.

– prophylactic diverticulectomy is done – if the diverticula has a narrow base if there is any palpable thickening or adhesions suggestive of ectopic tissue.

– if there is any attachment either by bands to the umbilicus or by a mesodiverticular vascular strand.

Ans. c. Etomidate