jejunum rupture

SURGERY CASE REPORTSURGERY CASE REPORT Created by Satya Wardhana, MD, General Surgeon

in Kanujoso Djatiwibowo Hospital Balikpapan East Borneo Indonesia

Case I :Man, 19 years old, came to hospital on July 11Man, 19 years old, came to hospital on July 11 thth, ,

2008 with chief complain: 2008 with chief complain: pain at the lower abdomenpain at the lower abdomen

History : Had been suffered since : Had been suffered since about 2 hoursabout 2 hours before admitted to the hospital cause of traffic before admitted to the hospital cause of traffic accident.accident.

Mechanism of Injury : Patient was riding motorcycle, : Patient was riding motorcycle, abruptly another motorcycle struck him from left abruptly another motorcycle struck him from left direction, then the patient fell to right direction and a direction, then the patient fell to right direction and a right wrist was pinned beneath handlebar of him right wrist was pinned beneath handlebar of him motorcycle.motorcycle.

Furthermore, the patien complained about pain at a Furthermore, the patien complained about pain at a right wrist too. No pain at right flank.right wrist too. No pain at right flank.

Micturation not yet since the accident.Micturation not yet since the accident.

Primary Survey::

A : patent

B : RR = 24 x/mnt, symetric, thoracoabdominal

type

C : PR = 88 beat/mnt, regular and adequat

BP = 120/80 mmHg

D : GCS 15 (E4M6V5)

E : normothermy, (axillary temperaturer = 37.1 oC)

Secondary Survey

Abdomen

I I : Convex, excoriated lesion and bulging at the left : Convex, excoriated lesion and bulging at the left

lower abdomen, synchronize with breath motion lower abdomen, synchronize with breath motion

(see picture below)(see picture below)

P : Tenderness and crepitation at left lower abdominal P : Tenderness and crepitation at left lower abdominal

wall, bulging can pull in and turn up again, wall, bulging can pull in and turn up again,

no defans muscular no defans muscular

PP : There were liver dullness and tympanic: There were liver dullness and tympanic

AA : There was bowel sound at bulging area, peristaltis : There was bowel sound at bulging area, peristaltis

was normal was normal

Digital Rectal Examination :

Sphincter tone was still tight, mucous layer was Sphincter tone was still tight, mucous layer was smooth, ampula empty, no collapse and no smooth, ampula empty, no collapse and no dilatation,dilatation,

Gloves : no blood, no slime, no fecesGloves : no blood, no slime, no feces

Abdomen X-Ray

Laboratory Findings

WBC : 22.3x103/µlRBC : 4.84X106µLHGB : 14.4 gr/dlHCT : 42,7 %PLT : 334.000/µLCT : 7’00”BT : 2’00”

Preoperation Diagnosis

Rupture of Small Intestine Cause of Abdominal Blunt Trauma

Management :

Stop oral intakeStop oral intake

IV-lineIV-line

Apply NGTApply NGT

Prophylactic antibioticProphylactic antibiotic

AnalgeticAnalgetic

Laparotomy explorationLaparotomy exploration

OPERATION PROCEDUREOPERATION PROCEDURE

Patient lied supine under general anesthesiaPatient lied supine under general anesthesiaSterilization procedure and drappingSterilization procedure and drappingIncision midline 3 finger above umbilicus until 3 finger above Incision midline 3 finger above umbilicus until 3 finger above symphysis pubissymphysis pubisDeepen until peritoneum, open peritoneumDeepen until peritoneum, open peritoneumFlew out blood about 300 cc derive from laceration of rectus Flew out blood about 300 cc derive from laceration of rectus abdominis muscle and aa. jejunalis abdominis muscle and aa. jejunalis Explorate solid organs did not find any laceration, continued Explorate solid organs did not find any laceration, continued explorate hollow viscus, found total jejunum laceration about 55 explorate hollow viscus, found total jejunum laceration about 55 cm from treitz’s ligament, laceration of jejunomesenterium about cm from treitz’s ligament, laceration of jejunomesenterium about 80 cm from treitz’s ligament80 cm from treitz’s ligamentPerform excision both of jejunum stump, then perform end to Perform excision both of jejunum stump, then perform end to end jejuno-jejunal anastomosis and stitches the mesenterium on end jejuno-jejunal anastomosis and stitches the mesenterium on both side.both side.Wash the abdomen cavity until clearly.Wash the abdomen cavity until clearly.Close the wound layer by layer without drainClose the wound layer by layer without drainOperation finished. Operation finished.

Incision midline 3 finger above umbilicus until 3 finger above symphysis pubis

Deepen until peritoneum, open peritoneum

Flew out blood about 200 cc derive from laceration of rectus abdominis muscle and aa. jejunalis

Explorate solid organs did not find any laceration

Explorate hollow viscusLaceration of jejunomesenterium about 80 cm from treitz’s ligament

Laceration of jejunomesenterium about 80 cm from treitz’s ligament

Perform excision both of jejunum stump

Perform tegel stich at both side

Continued end to end jejunojejunal anastomosis serosubmuscular continuous suture

End to end jejunojejunal anastomosis finished, continued Lambert’s suture

Stitches the mesenterium on both side with interuptus suture

Stitches the mesenterium on both side with interuptus suture finished

cranialcaudal

Postoperation DiagnosisPostoperation Diagnosis

Total Rupture of Jejunum

Laseration of Jejunomesenterial