Mandate

A few weeks ago I was awakened by a 2 a.m. call from the ED regarding a case of pneumoperitoneum. I barely recall the specifics of the conversation, but I vaguely remember snippets of phrases, words that light the fires and compel immediate action: "free air, tender all over, hypotension". I donned some old scrubs and quickly drove in to the hospital.The patient wasn't much older than me. He looked healthy, had a robust build. No other medical problems. But his vitals were perilously unstable. Heart rate 120's. Blood pressure 70 systolic despite several liters of fluid. The CT showed air under the diaphragm and inflammatory changes in the pelvis consistent with acute perforated diverticulitis. And he certainly had peritonitis on exam. I didn't have much of a choice. He needed an emergency operation.An hour later I had washed him out, resected the colon with the gaping hole, and fashioned an end colostomy. Primary anastomosis was not a consideration given the degree of contamination and pressor sustained systolics in the 80's. We call it theHartmann'sprocedure; an old school operation that is not used as often as it once was. We found that it isn't always so easy to reverse a colostomy (70% success rate) and the procedure itself can result in significant morbidity. Nowadays we find we can treat many cases of perforated diverticulitis medically with antibiotics alone. Primary anastomosis is performe...
Source: Buckeye Surgeon - Category: Surgery Authors: Source Type: blogs