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Primary Surgery Vol.2 – Trauma |  |
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Primary Surgery Vol.2 – Trauma | |
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For earlier steps in the operation, see Section 66.3. For methods of resecting gut, see Section 9.3. If, when you open the abdomen, there is a moderate amount of blood mixed with bile and intestinal juices, the patient’s small gut has been perforated. If there is no free fluid in his peritoneal cavity, his gut may still have been perforated, so search it carefully. In early cases ileus may minimize the leak. Search the patient’s small gut from end to end. Feel for its upper end, deliver it into the wound, search it carefully on both sides, and return it to his abdomen. Do the same with succeeding loops, until you reach his iliocaecal junction. Look carefully at his proximal jejunum, and his terminal ileum, because they are particularly likely to be injured. Be prepared to find several holes! When you find a rupture, take care not to lose it again, while you search for others. Wrap it in an abdominal pack, and hold it aside in a light clamp. To see if a clamp is light, try it on your little finger. If it crushes this, it is not light. Gut is normally sewn in two layers as in Section 9.3, the buried one to control bleeding, and the superficial serosal one to hold the gut together. However, these wounds rarely bleed by the time you see them, so you can use one layer, if you wish.
Use a purse string suture, and oversew this with Lembert sutures.
Use 2/0 chromic catgut on atraumatic needles to make a double layer of inverting sutures, in the transverse axis of the gut, as in Section 9.3.
Resect through healthy gut and anastomose it end–to–end. Suture the mesentery accurately, and avoid injuring its blood vessels.
Infold these with Lembert sutures (9.3), or cover them with,omentum. Don’t detatch this, leave it with its own blood supply.
If mesentery is injured, goto the next Section.
Drain the patient’s peritoneal cavity, and complete the laparotomy.
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Primary Surgery Vol.2 – Trauma | |
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