Surgery Rounds 4

Question 1

risks of foreign body surgery

Answer 1

• Necrotic (dead) bowel > possibility for RNA
• Dehiscence > 5-7 days
• Septic abdomen – tissue continuing to declare * Anesthetic complications
• Aspiration pneumonia – vomiting/regurgitation
• Surgical site infection
• NEGATIVE EXPLORE

Question 2

Evaluate viability of intestines (4 P’s):
- what to do if viable? if not?

Answer 2

1. Pink
2. Peristalsis
3. Palpation
4. Pulses
   <><><><>
   - If viable = enterotomy
   - If non-viable = resection and anastomosis (R&A)/ enterectomy

Question 3

Foreign Body – Viable Intestine
Enterotomy approach

Answer 3

1. Pack off intestinal segment
2. Doyens or fingers to hold off
3. Orad – towards the mouth > dilated
4. Aborad – towards the rectum > usually normal
5. Incise on the antimesenteric boarder
6. Slightly over foreign material into healthy intestine
   <><><><>
7. Incise with scalpel
8. Extend incision with Metzenbaum scissors
9. Ensure enterotomy is long enough for FB removal

Question 4

Foreign Body – Intestinal Closure

Answer 4

1. Full thickness
2. Appositional
3. Fine suture material (4- 0 PDS)
4. Leak test
5. Local lavage – remove
   sponges
6. Change gloves and instruments
7. Omental wrap
   <><>
   Tension tissue to help close

Question 5

leak test after enterotomy closure with viable intestine

Answer 5

• 10 mL saline
• 25-gauge needle
• 10 cm apart
• 5 cm orad
• 5 cm aborad

Question 6

Foreign Body – Non-viable Intestine
- surgical approach

Answer 6

1. Pack off intestinal segment
2. Orad – towards the mouth > dilated
3. Aborad – towards the rectum > usually normal
4. Doyens placed to preserve blood supply (angled)
5. Blood supply to affected segment is ligated

Question 7

Foreign Body – Non-viable Intestine
- how to place clamps?

Answer 7

Question 8

Foreign Body – Non-viable Intestine
R&A Closure Tips:

Answer 8

• Start at the MESENTERIC border
  > 2-3 sutures on either side
• Full-thickness, simple interrupted pattern
  > Split the distance with each bite
• 4-0 PDS
• Appositional
• Start with a surgeon’s knot to hold
• Suture closed the mesentery – watch blood supply

Question 9

R&A – Luminal Disparity - what should we not do when closing?

Answer 9

Question 10

Post R&A
- what do we do before closing?

Answer 10

1. Local lavage
2. Remove sponges
3. Change gloves and instruments
4. Omentalize
5. Lavage the abdomen
6. Close

Question 11

how to take an intestinal biopsy?

Answer 11

Question 12

Post-operative Care after removal of foreign body from intestine?
- when might we see dehiscence and what should we watch out for?

Answer 12

• Opioid analgesia
• NO NSAIDS (or STEROIDS)
  <><>
• Enteral nutrition ASAP
• +/- Pro-motility (metoclopramide)
  > Enterotomy vs R&A
• Anti-emetic (maropitant)
• +/- Antibiotics (surgery type)
  <><>
• Dehiscence – 3-5 days post operatively
• FIRST SIGN IS INAPPETENCE AND VOMITING