Intestinal occlusion in a patient with a complex abdominal wall defect
Posted in Pictures on 9 October 2015
Juan José Espert Ibañez (Gastrointestinal and abdominal wall surgery senior consultant)
César Ginesta Martí (Emergency Surgery Specialist)
Alberto Martínez Peral (Emergency Surgery Specialist)
Hospital Clínic, Barcelona – Spain
A 71 year old patient with a history of type 2 DM, HBP and liver transplantation for enol and HCV (30/03/2005) associated with a complex abdominal wall defect secondary to transplantation surgery.
The patient was admitted to the emergency department of our hospital with symptoms of malaise, fatigue, anorexia and loss of weight (10 kg in 2 months).
He was hemodynamically stable, conscious and oriented in time and space. Febricula 37.5 ° C. Physical examination showed signs of severe dehydration, depressible and soft abdomen with no signs of peritonitis and 2 large uncomplicated hernias .
We decided to perform a CT Scan, which showed an occlusive/subocclusive neoplasm in the splenic flexure of the colon with some small nodules in the adjacent fat, probably locoregional lymph nodes. Marked distention of the entire colon which was inserted into two major abdominal wall hernias. The ileocecal valve was not fully competent (FIG. 1).
Subsequently colonoscopy was performed for placement of a stent to deal with intestinal occlusion. This maneuver made it possible to wash the colon and then operate on the patient in a regulated way 48 hours later.
We performed a supraumbilical incision over the hernia entering into the abdominal cavity. We identified the colon neoplasia in the splenic flexure and we performed an extended right hemicolectomy with a mechanical side to side ileocolic anastomosis.
We then proceeded to repair the abdominal wall. Component release was performed, freeing the transverse muscle and the back fascia of the higher rectus abdominis muscle. We placed a Vicryl mesh sublay, continuing with the subsequent closure of the back aponeurosis. We placed another onlay polypropylene mesh and then a T abdominoplasty was performed ending the surgery (FIG. 2).
The surgery took 244 minutes.
As complications during admission, the patient presented with a respiratory infection with secondary respiratory failure requiring tracheal intubation and admission to the intensive care unit. He had a satisfactory progress with antibiotic treatment so that he could be extubated. He was later transferred to the general surgical ward presenting a correct development with good tolerance to the progressive oral diet.
Histopathology revealed an Intestinal Invasive Adenocarcinoma, moderately differentiated, without evidence of lymph node metastasis. No factors of poor prognosis and free surgical margins (pT3N0M0).
The patient was discharged after 20 days.
The aesthetic and functional results of the abdominal wall were satisfactory as can be seen in the picture a month after the intervention (FIG. 3). The patient is currently asymptomatic, disease-free and the abdominal wall is integral with a good cosmetic result.