1. MORBIDITY CONFERENCE
R2楊智裕/VS廖志思

2. Patient profile
Name: 張○ ○
Age: 46 y/o
Gender: male
住院日期: 2011/10/28-

3. Chief complaint
Abd fullness, epigastric dull pain for 3 days

4. Present illness
abd fullness, epigastric dull pain for 3 days prior to admission
epigastric/RUQ pain after meal intake
fever(-)
stool amount decrease
echo (LMD): inconclusive
on admission: nausea/vomit at ER  NG decompression

5. Past history MVA, internal bleeding, laparotomy (2004.2)
GI ward admission in 2006 for acute cholecystitis no Op.
No HTN, No DM, No other medical disease
MVA, internal bleeding, laparotomy (2004.2)
Complete transection of distal jejunum with multiple disruption of small bowel
Question of small bowel resection (?)

6. Physical examination Abdomen soft and flat; Op scar at midline;
Vital signs: 36.8, 74, 18, 139/92
HEENT: non-icteric sclera
Skin: no jaundice
Abdomen
soft and flat; Op scar at midline;
Tenderness, mild at RUQ, negative Murphy sign Rebounding pain (-)
Tympanic on percussion
Bowel sound, hypoactive
Liver/Spleen: Impalpable

7. Lab Hb 15.7 WBC 10600; seg 86.3 GOT/GPT 43/90 ALK-P 80.1 (normal)
Amy/lipase 58/17.8 (normal)
Bil.T/D 1.10/0.36
CRP 0.427

8. X-ray

9. Initial diagnosis
Gallstone
CBD stone
r/o ileus

10. Abd CT

11. Treatment course
10/28 admission
10/29 ERCP

12. 10/30 1st OP laparoscopic cholecystectomy
umbilical port: open method, small intestine was met
convert to subxyphoid port, open method
3 additional ports created: right paraumbilicus port for scope; mid clavicle subcostal, ant axillary lat abdomen
r’t subhepatic for J-P drain

13. 10/30-11/2 POD1-3
10/30-11/2 Post-OP
Flumarin 1000mg Q8H
Vital signs normal, no fever
Drain: 105cc, 10cc, removed
Wound clear
POD1 on soft diet smooth
11/2 pm POD3: bile-like fluid from umbilical wound
Susp. small bowel perforation

14. 11/3 POD4 (2nd OP) OP: laparoscopic enterolysis + small bowel repair
adhesion of small bowel to the peritoneum at the umbilical region  enterolysis
one 0.5 cm small bowel perforation
extended paraumbilical wound & closure of perforation
the umbilical wound open care

15. 11/4-11/9 POD1-6
11/4-11/8 Post-OP
Flumarin 1000mg Q8H
Vital signs normal, no fever
wound ok, no abnormal wound pain
Try water since 11/8 (POD5)
11/9 (POD6) pus-like discharge from umbilical wound
Debridement at bedside

16. 11/10-11/11 POD 7-8 11/10 pus-like discharge at umbilical wound
remove stitches of r’t paraumbilical wound, turbid fluid discharge
Debridement at bedside
11/11 still turbid discharge
Peritoneal sign (-)
Lab: WBC 8940, seg 73.3

17. 11/11 POD8 (3rd OP) OP: explore Lapa (with enterolysis + resection)
Midline incision
finding: small bowel perforation: 220cm proximal from ileocecal valve;
several adhesion over small intestine  enterolysis
segmental resection of small bowel about 100cm including the perforation site

18. Post-OP (3rd) NPO + NG decompression TPN
Cefmetazole 2000mg Q12H  11/14 Maxipine 500mg Q12H
Lab data: unremarkable
Stool(+) in the first week

19. 11/18 POD7 11/18-11/19 try oral intake to 稀飯 smooth 11/20 vomit(+)
X-ray: ileus
NPO with NG for drainage
TPN

20. 11/16-11/20 POD 5-9
X-ray: 11/16, 11/18, 11/20

21. 11/25 POD 14
Upper GI series
Adhesion  ileus  with  proximal jejunum  obstruction & stenosis.

22. 11/26 POD15 4th OP
Explore. Lapa
severe adhesions underneath the fascioperitoneal layer
marked adhesions and tissues lumped together and the whole procedure was stopped due to high possibility of injuring lot of bowels

23. Post OP 11/26-11/30 POD 1-4 NPO with NG TPN change to PPN
On liquid diet with NG on
NG output decreasing despite intake
Oral intake 200cc qd  1000cc qd

24. 12/5 POD9 small bowel series
Focal  adhesion  in  proximal  jejunum  with  partial  obstruction 

25. 12/7 POD11
12/7 X-ray colon gas (+)

26. 12/7-12/19 POD11-23 Increasing amount of oral intake
Oral intake range cc qd
Liquid & semi-solid diet
Occasional vomiting with spontaneous relief

27. Discussion

28. Complication Laparoscopic related bowel injury
Post-OP adhesion & small bowel obstruction

29. Bowel injury as a complication of laparoscopy
Incidence
Bowel injury (0-10%)
Bowel perforation (0.07-8%)
Mortality 16/430 (3.6%)
British Journal of Surgery 2004; 91: 1253–1258

30. Bowel injury as a complication of laparoscopy
Location
Time of diagnosis

31. Bowel injury as a complication of laparoscopy
Instrument involved
Management

32. Case series I (Egypt)
Management of laparoscopic-related bowel injuries Surg Endosc (2000) 14: 779–782

33. Case series I (Egypt) Presentation (7 late diagnosis)
Septic shock: 3 pts
Localized or diffuse peritonitis: 4 pts
Image confirmation (X-ray US CT): 4 pts
Air under diaphragm
Distended bowel loop with multiple fluid level
Intraabdominal abscess

34. Case series I (Egypt)
Outcome: mortality 3/12 (25%)

35. Case series II (Netherland)
LAPAROSCOPIC BOWEL INJURY: INCIDENCE AND CLINICAL PRESENTATION TION J.urology V161, , Mar 1999
915 laparoscopcic urological procedures
8 bowel abrasion or perforation
2 other unrecognized bowel injury included

36. Case series II (Netherland)
Presentation in this series
Typical presentation of delayed diagnosis
ileus,
worsening abdominal pain,
abdominal rigidity, leukocytosis with a left shift,
fever and large volume fluid requirements
Followed by tachycardia and hypotension.

37. Adhesion & bowel injury
Inadvertent enterotomy during reopening of the abdomen or subsequent adhesion dissection is a feared complication of surgery after previous laparotomy. The incidence can be as high as 20% in open surgery and between 1% and 100% in laparoscopy depending on the underlying disease.
Consequences and complications of peritoneal adhesions. The Association of Coloproctology of Great Britain and Ireland, 9 (Suppl. 2), 25–34

38. Laparoscopy or not
There is no reason to avoid laparoscopic procedures in most patients with prior abdominal surgery despite a higher conversion rate (5.2% vs 2.6%), but caution is warranted in patients who have undergone major gastrointestinal-tract surgery.
Laparoscopic colorectal surgery in patients with prior abdominal surgery. Dig Surg. 2011;28(1):22-8.

39. Identify adhesions
TAU (transabdominal ultrasound) can accurately identify IAA (intraabdominal adhesions) prior to laparoscopy. Widespread application of this technique may decrease trocar-related injuries during laparoscopic procedures in patients with previous abdominal surgery.
Use of transabdominal ultrasound to identify intraabdominal adhesions prior to laparoscopy: a prospective blinded study. Am J Surg Dec;192(6):843-7

40. Modified entry
Left ninth intercostal space was used for Veres needle entry, and the primary trocar was placed in the left upper quadrant space.
Of the 504 potentially risky entries, there were two (0.39%) Veres-needle related and zero trocar-related injuries.
Safe entry techniques during laparoscopy: left upper quadrant entry using the ninth intercostal space--a review of 918 procedures. J Minim Invasive Gynecol Sep-Oct;12(5):463-4

41. Mechanism of Adhesion formation

42. Factors influencing adhesion formation
Previous operation
Abdominal or pelvic irradiation
Incision site
Presence of blood / pus / inflammation
Foreign material / suture
Means of peritoneal closure
Open surgery / laparoscopic surgery

43. Adhesion-related small bowel obstruction
2007 The Association of Coloproctology of Great Britain and Ireland, 9 (Suppl. 2), 39–44

44. Small bowel obstruction
Common symptom
colicky abdominal pain;
nausea and ⁄ or vomiting;
constipation;
abdominal distension.
Cause
Intra-abdominal adhesion
Previous operation
other

45. Diagnostic point Clinical examination Make accurate diagnosis
Incision scar  suggest adhesion
Hernia
Localized peritonitis & distended ischemic loop of bowel
Make accurate diagnosis
Whether impending, or actual, bowel ischemia (strangulation) is present

46. Radiology of SBO
Coiled spring sign
Air-fluid level

47. String-of-pearls sign
Radiology of SBO
String-of-pearls sign
Slit/stretch sign

48. Radiology of SBO Water-soluble contrast study
Differentiate complete & partial obstruction
no associated complications, shortens the time to surgery in those who require it and the time in hospital and time to resumption of oral diet

49. Radiology of SBO CT scan Ultrasound Identification of strangulation
reduced mural enhancement, ascites and mesenteric congestion
Ultrasound
assessing the level of obstruction
the presence of strangulation

50. Managing adhesive SBO
‘not letting the sun set on a case of small bowl obstruction’
no longer considered a useful management strategy.
Conservative treatment
drip (IVF) & suck (NG decompression)
repeated clinical assessment
Immediate operation for bowel ischemia

51. Managing adhesive SBO
No absolute criteria as to the actual timing of intervention
For adhesion, prolonged conservative treatment and avoid high-risk procedure
Laparoscopic treatment
Diminish the rate of post-operative adhesion
Manage adhesive SBO by laparoscopy
Favorable for simple band adhesion

52. Our case Intra-abdominal adhesion due to previous laparotomy
Unrecognized small bowel injury during laparoscopy
Small bowel perforation  simple repair (laparoscopic)
Delayed diagnosis of secondary small bowel perforation  segmental resection (laparotomy)

53. Our case Post-OP adhesion related small bowel obstruction
Prolonged conservative treatment (+ unsuccessful laparotomy)
Intestinal patency after 24 days post 3rd operation

54. 健康照護矩陣(Health Care Matrix, Bingham Quinn, 2004)
IOM Aims
ACGME
Competencies
防止傷害
SAFE
及時不拖延
TIMELY
醫療正確
EFFECTIVE
資源不浪費
EFFICIENT
公平的對待
EQUITABLE
以病人為中心PATIENT-CENTERED
照護品質及問提的評估 Assessment of Care
病人照護
（有或沒有問題）
Patient
Open method of laparoscopy entry
diagnostic uncertainty of bowel perforation
醫學知識
Medical Knowledge & Skills
人際溝通技巧
Interpersonal & Communication Skills
專業素養
Professionalism
insufficient information
about procedure
制度下的臨床工作
System-Based Practice
added cost of hospital stay from complication
提出改進方案 Improvement
執業中學習與改進
Practice-Based Learning & Improvement
be aware and on guard of complication
Hospital policy
Informed
Consent
Information Technology
© 2004 Bingham, Quinn Vanderbilt University