TEARS AND HAEMATOMAS OF THE MESENTERY

For the earlier steps in the operation, see Section 66.3.

Suspect rupture of the mesentery if there is free bleeding in the centre of the patient’s abdomen.

Assess the viability of his gut by the methods in Section 10.5. If gut is not viable, resect it.

TEARS IN THE MESENTERY

To avoid the danger of internal hernias, close all tears by the method in Fig. 66-16. Take great care to avoid blood vessels, especially those close to the border of the gut.

If a tear is close to the gut, parallel to it, and more than 3 or 4 cm long, resect the neighbouring gut.

If part of the gut looks non–viable, resect it.

If you are in doubt about the viability of a piece of gut, make a shallow incision through its antimesenteric border, opposite the centre of the tear. If it bleeds actively, it is viable, so control bleeding and leave it. If it does not bleed, resect it.

CAUTION! (1) Don’t clamp, or tie off, or include in your sutures, any vessels which might impair the blood supply to the gut. (2) Don’t try to bunch the mesentery together to tie it.

HAEMATOMAS OF THE MESENTERY

There are two common sites, the mesentery of the small gut and that of the sigmoid colon.

IN THE MESENTERY OF THE SMALL GUT, management depends on whether or not the haematoma shows signs of spreading.

\includegraphics[width=\linewidth ]{/home/kumasi/Desktop/primsurg-tex/vol-2/ch-66/fig/66-17.eps}
Figure 66.17: MORE PENETRATING INJURIES OF THE SMALL GUT A, suturing a transverse laceration. B, a purse string repair for a small laceration. C, extensive multiple wounds are being resected. D, a tear in the mesentery is being sutured. E, a longitudinal tear and the adjacent gangrenous gut are being excised. F, a haematoma is being incised. Adapted from an original painting by Frank H. Netter, M.D. from The CIBA collection of medical illustrations, copyright by the CIBA Pharmaceutical Company, Division of CIBA–GEIGY Corporation. With kind permission.

If the injury was several hours ago, and the haematoma has well defined edges, and looks as if it is not going to spread, leave it alone.

If the haematoma shows any sign of spreading, control bleeding by pinching the bleeding vessel between your finger and thumb. Open the haematoma, remove the clot, and swab it free of blood with a swab. Then momentarily release your finger and thumb, and find and tie the bleeding vessel.

If a haematoma bleeds and the gut is viable, insert some haemostatic sutures and wait 10 minutes. If it is still viable when you return, leave it. If it is not, resect it.

If the gut is not viable, resect it.

IN THE MESENTERY OF THE SIGMOID COLON, large haematomas are common after fractures of the pelvis. Sometimes the pelvic cavity is obliterated by bulging peritoneum filled with clot. Leave a haematoma unless it pulsates and enlarges showing that a major artery is torn and needs tying or repairing.

DIFFICULTIES WITH A GUT INJURY

If a patient BLEEDS PER RECTUM postoperatively, watch him. All patients with a gut injury pass some blood in their stools. If he has no signs of peritonitis, there is probably no need to reoperate. But, if bleeding is continuous or signs of peritonitis develop, do another laparotomy.