Stomach Surgery

[SavageGlow]

We present the case of a 59-year-old female who presented to our academic level I trauma center with SBS secondary to an MVC. The initial workup identified the following injuries: eviscerated bowel, degloving of the lower abdominal wall, bilateral groin lacerations, left common iliac artery dissection, retroperitoneal hematoma, left femoral nerve injury, transected musculature (psoas, left obliques, and bilateral rectus abdominis), and various fractures (seventh cervical vertebra, left transverse process of the first lumbar vertebra, anterior superior endplate of the second lumbar vertebra, left 10th rib, right third proximal phalanx, right ankle, and nasal bones). She was taken to the operating room (OR) for an emergent exploratory laparotomy. Figures 1 and 2 display some of the intraoperative findings during the initial assessment.

The abdominal wall had been sheared from the left anterior superior iliac spine to the paraspinous muscles posteriorly. A systematic evaluation of the abdomen revealed areas of devitalized small bowel mesentery and sigmoid colon transection that both required segmental resections and were left in discontinuity during the initial operation.

She was taken back to the OR on hospital day (HD) 1 for further small bowel and sigmoid colon resection and anastomosis. Evaluation of the abdominal wall revealed transected parts of the right internal and external abdominal obliques, transversalis abdominis, and rectus abdominis musculature with partial transection of the psoas muscle. The transection extended circumferentially along the left side to the paraspinous muscles. The femoral nerve was exposed with additional transection of the ilioinguinal nerve and other cutaneous nerves of the retroperitoneum (Figure 3).

Then, 24 x 13 cm of devitalized skin, fat, and muscles was debrided. The patient was closed again with a negative pressure device with an intent to return shortly for further abdominal wall closure.

On HD 3, the patient returned to the OR for repair of the transected left abdominal wall. The posterior abdominal wall was sutured together, and the internal oblique and transversalis abdominis musculature were sutured to the fascial insertions at the pelvic brim. The external abdominal oblique musculature was elevated off the internal oblique to provide length and bring it down to the anterior abdominal wall. An absorbable poly-4-hydroxybutyrate (P4HB) mesh was placed over the fascia lata across the pelvic brim and onto the internal oblique fascia, suturing it to the fascia lata and internal oblique musculature (Figure 4).

The external oblique was then brought over the mesh and sutured down with transfascial sutures through the abdominal wall, including both the mesh and the external oblique. Due to third spacing and edema, the midline wound was unable to be closed. The rectus sheath also had considerable tissue loss and could not be fully reapproximated over the left rectus abdominis. A negative pressure device was again placed over the abdomen with plans to return shortly for an underlay repair.

On HD 5, the patient returned to the OR. The midline fascia could not be reapproximated to its original position due to edema, so a cadaveric dermis mesh underlay was performed with additional repair of an incarcerated ventral hernia (Figure 5).

Granulating mesh was chosen since a large area in the left lower quadrant could not be covered by tissues without transfer. A negative pressure device was again placed. On HD 7, the patient returned to the OR for washout and possible abdominal closure; however, the skin and soft tissue were unable to be brought together primarily, and 100 cm2 of devitalized skin, fat, and muscle was debrided. On HD 9, the patient returned to the OR for fasciocutaneous advancement flap on the left to close the soft tissue gap. Multiple drains were placed to prevent postoperative seroma collection. Scarpa's fascia and the overlying skin were advanced to provide adequate skin coverage of the left abdomen. This layer was sutured to the anterior abdominal fascia and reapproximated over the entire 63 cm length of the incisions to close these spaces. All the skin laceration incisions were able to be reapproximated except for a 4 x 6 cm location overlying the mons pubis. A negative pressure device was placed here. A zip line closure was also placed over the left abdominal closure to help reapproximate the skin and offload the incision tension (Figure 6).

The patient was maintained in 30 degrees of flexion with physical therapy (PT) support for one week postoperatively to limit abdominal wall tension. She was advanced to a pivot to chair without extension on HD 19. The wound vac over the mons pubis was removed on HD 23. After she became tachycardic on HD 26, imaging revealed an anterior abdominal wall fluid collection. Interventional radiology (IR) performed a percutaneous drainage catheter placement into the collection. Cultures revealed methicillin-resistant Staphylococcus aureus, and she was started on IV vancomycin. Another IR drain was placed into a right anterior abdominal wall collection on HD 30. She improved incrementally and was discharged on HD 53.

The patient remained stable for approximately one year and returned for outpatient evaluation of an incarcerated ventral hernia 366 days after the initial admission. Given that she had already undergone component separation and complex abdominal wall reconstruction on the left side from the initial injury, a novel approach was taken with Botulinum toxin (Botox) to increase the likelihood of primary fascial closure. She received 300 total units of Botox diluted 3:1 with sterile saline (50 each in the left external intercostals, right external intercostals, left internal intercostals, right internal intercostals, left transversus abdominis, and right transversus abdominis) 418 days after the initial hospital admission. The patient was readmitted for open ventral hernia repair with mesh and a myofascial advancement flap on the right 433 days after the initial admission. The Botox injections had allowed for the fascia to be approximated to the midline (Figure 7).

A mesh with a nonabsorbable polypropylene layer surrounded by polydioxanone reinforced the repair. The patient was last seen 541 days after the initial accident, recovering well with no signs of hernia or reconstruction failure.

[Mr.NoCredit]

Fuck what a total nightmare for this person.

From reading it would seem she was in some kind of car accident or something very traumatic to the body. Car wreck would be my guess.

[Elizabeth76]

Ugh what a mess! Lucky to be alive!