Jejunum Rupture

SURGERY 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 11th, 2008 with chief complain: pain at the lower abdomen

History : Had been suffered since about 2 hours before admitted to the hospital cause of traffic accident. Mechanism of Injury : Patient was riding motorcycle, abruptly another motorcycle struck him from left direction, then the patient fell to right direction and a right wrist was pinned beneath handlebar of him motorcycle. Furthermore, the patien complained about pain at a right wrist too. No pain at right flank. 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 : Convex, excoriated lesion and bulging at the left lower abdomen, synchronize with breath motion (see picture below) P : Tenderness and crepitation at left lower abdominal wall, bulging can pull in and turn up again, no defans muscular P : There were liver dullness and tympanic A : There was bowel sound at bulging area, peristaltis was normal

Digital Rectal Examination : Sphincter tone was still tight, mucous layer was smooth, ampula empty, no collapse and no dilatation, Gloves : no blood, no slime, no feces

Abdomen X-Ray

Laboratory Findings WBC RBC HGB HCT PLT CT BT

: 22.3x103/µl : 4.84X106µL : 14.4 gr/dl : 42,7 % : 334.000/µL : 7’00” : 2’00”

Preoperation Diagnosis Rupture of Small Intestine Cause of Abdominal Blunt Trauma

Management : Stop oral intake IV-line Apply NGT Prophylactic antibiotic Analgetic Laparotomy exploration

OPERATION PROCEDURE Patient lied supine under general anesthesia Sterilization procedure and drapping Incision midline 3 finger above umbilicus until 3 finger above symphysis pubis Deepen until peritoneum, open peritoneum Flew out blood about 300 cc derive from laceration of rectus abdominis muscle and aa. jejunalis Explorate solid organs did not find any laceration, continued explorate hollow viscus, found total jejunum laceration about 55 cm from treitz’s ligament, laceration of jejunomesenterium about 80 cm from treitz’s ligament Perform excision both of jejunum stump, then perform end to end jejuno-jejunal anastomosis and stitches the mesenterium on both side. Wash the abdomen cavity until clearly. Close the wound layer by layer without drain 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 viscus Laceration 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

caudal

cranial

Postoperation Diagnosis Total Rupture of Jejunum Laseration of Jejunomesenterial