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Git perforation
- 1. GIT PERFORATION BY DR. CHANDRESHMANGAROLIYA M.S. - GENERAL SURGERY (National Institute of Medical Sciences & Research)
- 2. PERITONEUM ANATOMY AND PHYSIOLOGY •Serous membrane lining the abdominal cavity • Outer fibrous tissue (provides strength) • Inner mesothelial layer (lubricating function) • Parietal peritoneum : lines the inner surface of the abdominal wall, under surface of diaphragm and pelvic wall. • Loosely attached to overlying walls. • Supplied by sometic nerves so pain sensitive • Viseral peritoneum : lines outer surface of abdominal viscera. • Firmly adherent • Supplied by autonomic nervous system
- 3. PERFORATION • Causes : •Perforation of distal oesophagus • Perforation of stomach • Perforation of small intestine • Perforation of large intestine • Perforation of biliary tract • Following penerating wound like gunshot injury to abdomen or stab wound • Causative organisms: • Escherichia coli(most common) • Others: Streptococci, Clostridium welchii, bacteroides, staphylococci, Klebsiella, Salmonella typhi.
- 4. • OESOPHAGEAL PERFORATION: • acute emergency and needs immediate surgical intervention • Causes : • INSTRUMENTATION • Endoscopy (during dilatation of strictures,injection sclerotherapy) • Corrosive poisoning • Caustic injury • OESOPHAGEAL DISEASE • Carcinoma (barrett’s oesophagus) • SPONTANEOUS RUPTURE • Boerhaave’s syndrome (left postero lateral wall of lower 1/3 oesophagus)
- 5. • Clinical features: • severe pain in neck , chest , abdomen. • Dysphagia • Dyspnoea • Haemetemesis • Pleural effusion • Tachycardia • Shock • ‘Hamman’s sign’ : due to escape of air into the mediastinum gives mediastinal crunch sound which produce by heart beating against air filled tissues
- 6. • INVESTIGATIONS • XRAY CHEST PA VIEW • Shows pneumomediastinum • CT CHEST • Diagnostic • TREATMENT • If history of perforation is within 24 hours then closure of perforation and external drainage should be done. • If history is of >24 hours then Transhiatal oesophagectomy • Four phases : Initially, the abdomen is opened and assessed for metastasis and resectability. The stomach is mobilized in preparation for resection. • In the second phase esophageal hiatus is widened and mediastinal esophagus is mobilized. • In third phase through the cervical incision the cervical esophagus is mobilized and upper mediastinal dissection is performed. • Finally the esophagus is resected and the stomach tube is created which is brought up in the neck and esophagogastric anastomosis is done.
- 7. • Procedure • Uppermidline incision is placed. Often upper horizontal or bilateral subcostal may be used. Self-retaining retractor is placed. • Abdomen explored left lobe of the liver is mobilised. Traction is given to stomach. Oesophagogastric junction is identified . • Peritoneum and phrenooesophageal ligament is incised . • Retrooesophageal window is created by sharp and blunt dissection. Accessory hepatic artery may be ligated. Short gastric vessels are ligated . • In the neck an oblique incision is made along the antterior border of leftt lower sternocleidomastoid muscle extending from left side of suprasternal notch to level of thyroid cartilage.through this incision the upper oesophagus is dissected and freed from trachea.
- 8. • GASTRIC PERFORATION: • Less common then duodenal perforation • Most common site is prepyloric region or lesser curvature • Pt will have history of taking alcohol,steroids,NSAIDS • H/O weight loss • Signs and symptoms • PAIN • Initially in epigasrium • Burning in nature • Aggravates on taking food and relieved by induced vomitting • On perforation initially pain is in epigastrium • Later on it goes to right side of abdomen • Then it becomes generalised • TENDERNESS • Rebound (blumberg sign) • Abdominal distention • Dullness over flank
- 9. • Obliteration ofliver dullness • Fever,Vomitting,Dehydration,Oliguria • Tenderness in P/R examination
- 10. • DUODENAL PERFORATION •Common in males in 1st part of duodenum • Mostly followed by chronic duodenal ulcers • Rest due to silent perforation • Pt will have history of steriods,alcohol,NSAIDS. • Sign symptoms • PAIN • Initially in epigastrium • Sudden in onset • Persistently localised to epigastrium relieves on taking food. • On perforation initially pain is in epigastrium. • Later on it goes to right side of abdomen • Then it becomes generalised • TENDERNESS • Rebound (blumberg sign) • Abdominal distention • Dullness over flank
- 11. • Obliteration ofliver dullness • Fever,Vomitting,Dehydration,Oliguria • Tenderness in P/R examination • INVESTIGATION • Xray Flat Plate Abdomen (Erect position) • Gas under diaphragm • Absence of gas can be. due to Gas leak is < 1ml , Sealed peptic ulcers • False diagnosis due to interposition of colon infront and above the liver. • USG whole abdomen : Fluid and Gas • TLC,Electrolytes,S.urea,S.creat • Four quadrent abdominal tap
- 12. • SURGICAL INTERVENTION •Emergency laparotomy should be done. • Procedure : • Emergency laparotomy through upper midline incision is done. All infected fluid is removed by suction. Perforation is identified. • Usually duodenal ulcer perforation is less than 1 cm in size. Giant ulcer is more than 2 cm in size. Omentum will be adherent to the site of perforation. It is gently separated. If duodenum is not perforated then stomach, posterior wall of stomach (lesser sac), small bowel and colon are thoroughly checked for possible sites.
- 13. • Once perforationis identified, suction of surrounding area is done. Liver, colon and proximal stomach are retracted. Suture material used for perforation is 3-0 vicryl. • As perforation edge is friable and oedematous, needle bites should be very gentle. Bite from each edge (5 mm from the edge) is taken separately. Each suture is kept away using haemostats on either side untied. Three stitches are taken at equal distances.
- 14. • SMALL INTESTINALPERFORATION • Causes : • Predisposing conditions like, • Crohn’s disease • Enteric perforation • Tubercular perforation • Appendicular perforation • Penetreting injury
- 15. • Clinical features: • Crohn’s disease : • Common in terminal ileum and colon • Abdominal pain with Chronic diarrhoea • Perianal ulcers and fissures • Involves full thickness of intestinal wall • Skip lesions • Enteric perforation : • Mostly occurs in 3rd week of infection • fever(step ladder) • Chills • Abdominal pain • Distention • Diarrhoea • Rose spots on abdomen (due to vasculitis)
- 16. • Tubercular perforation: • Mostly occurs in acute ulcerative variety • Affects ileocaecal region • Occurs due to swallowing of TB bacilli • Initially pt will complain of blood and mucus comes in stool • Associated with diarrhoea • Abdominal pain • Distention • Ulcers will be transverse
- 17. • LARGE INTESTINEPERFORATION • Cause : • Diverticulitis of colon • Ulcerative colitis • Carcinoma colon • Clinical features : • DIVERTICULITIS • Left sided lower abdominal pain • Relieves on passing of flatus or stool • Associated with bleeding P/R • Low grade fever • Tenderness , rigidity • Mass felt in left iliac region • Once it rupture it gives features of peritonitis • INVESTIGATIONS • Sigmoidoscopy : mucosa may be erythematous and opening of diverticuli seen • Colonoscopy
- 18. • ULCERATIVE COLITIS •Patient comes with H/O excessive urge to pass stool • Stool contains blood and mucus • INVESTIGATIONS • Stool examination to rule out infective cause (amoebiasis,shigella) • Sigmoidoscopy : multiple ulcers visible • Colonoscopy : to find out extent of involvement and to take biopsy • CARCINOMA COLON • C/O unexplained weakness , anaemia • Occult blood in stools • Changes in bowel habits • Perforation more common in left sided ca colon
- 19. • INVESTTIGATIONS : •CBC • Stool examination • Barium enema : shows persistent filling defect (apple core deformity) • USG • CT scan • Colonoscopy (growth will be seen)
- 20. Signs and Symptoms •Sudden onset of pain which is severe. • Fever • Vomiting • Tenderness—initially localised later becomes diffused. • Rebound tenderness—Blumberg sign. • Guarding and rigidity, dull flanks on percussion. • Tachycardia, tachypnoea. • Tenderness on P/R examination. • Distension with silent abdomen. • Eventually leading to Hippocrates facies, septicaemic shock and loss of consciousness. • Bowel sounds are absent due to paralytic ileus. • Fever may be absent in severe peritonitis due to loss of pyrogenic reaction. Total count also may be very low in severe peritonitis.
- 21. INVESTIGATION • Xray FPA(Erect posture) • CBC • USG Whole Abdomen • Blood urea and Serum creatinine • S.Amylase and S.Lipase • BT ,CT,PT INR • Four quadrant abdominal tap or USG guided aspiration of fluid • Diagnostic laparoscopy • CECT Whole Abdomen
- 22. TREATMENT 1. Medical Management 2.Surgical Management 1. Medical Management • IV fluids : To correct tissue perfusion,hypovolemia and improove urine output. • Nasogastric tube aspiration : To reduce toxic fluid and to decompress bowel. • Total parentral nutrition • Blood,plasma,platelet transfusion • Catheterisation with maintainence of adequete urine output
- 23. • Antibiotics :ampicillin, gentamicin, metronidazole, ceftazidime, cefoperazone, cefotaxime, tazobactum, piperacillin, meropenem, linezolid, etc. • Analgesics to relieve pain by drugs • Surgical correction of underlying cause.
- 24. SURGICAL INTERVENTION Exploratory laparotomy •On laparotomy cause for perforation peritonitis identified and corrected • In bowel perforation : Resection and anastomosis • In perforated appendicitis : Appendicectomy • Proper peritoneal toilet should be done • Pus send for c/s
- 25. • Procedure : •Antimesenteric border is having least blood supply and is so critical point in bowel anastomosis. So antimesenteric border should be cut obliquely while doing bowel anastomosis. Mesenteric arterial pulsation should be checked. Cut edge bleeding is very important. If surgeon is not satisfied about cut edge bleeding then one should trim the edge adequately • Colour, peristalsis, pulsation in the arcade, bleeding suggests adequate blood supply. • Serosal area should be cleared off from fat for 1 cm margin before doing bowel anastomosis. Fat will interfere with proper apposition of the cut edges. It also reduces the blood supply .
- 26. • Luminal sizeof the anastomotic segments should be near equal to have proper serosal apposition. If it is not then narrower segment should be widened by incising antimesenteric border obliquely to widen the lumen (Cheatle’s cut). Usually distal collapsed part will be narrower compared to proximal dilated segment; so commonly distal part needs Cheatle’s cut . • Knot should be tied with only optimum force.it should be neither be very tight nor very loose. • While suturing anterior layer one should be careful in avoiding inadvertent bites of the posterior layer which will block the lumen partially causing stricture and obstruction. Bites should be taken at 5 mm gap with 5 mm thickness of tissue from the cut edge.
- 27. • Non traumaticclamps over the bowel should be placed at 30 degrees at antimesenteric border. Clamps should not extend far into the mesentery. Occlusion clamps are applied at viable part to prevent spillage of contents into peritoneal cavity, to prevent oozing from cut edges of the bowel and to stabilize the gut. Crushing clamps are placed after ligation of mesentery just prior to cutting the bowel; it is applied on the specimen side. One should take care about avoiding twisting of mesentery prior to anastomosis after resection. • Corners of the cut edge of the bowel should be held with seromuscular sutures or Babcock’s forceps to allow posterior layer to drop behind and to facilitate proper bite taking of the cut edges.
- 28. • Anastomosis canbe done as continuous layer or interrupted sutures. In acute conditions as there is oedema interrupted one is better. Single layer interrupted sutures are safer and equally good. If two layer anastomosis is done outer interrupted silk sutures are used; inner continuous absorbable sutures like vicryl are used.
- 29. POST OP CARE •Proper critical care (ICU) postoperatively. • Ventilatory support; monitoring with urine output, temperature, breathing, pulse rate, blood pressure, arterial blood gas analysis, total count estimation (both very high and very low counts signify severe sepsis/septicaemia), platelet count, prothrombin time analysis, blood urea and serum creatinine, liver function tests (altered liver function signifies septicaemia). These investigations need to be repeated as and when required . • Proper fluid and electrolyte management. • Total parenteral nutrition . • Prevention of deep vein thrombosis by leg exercises, low molecular weight heparin. • Prevention/identification of ARDS and its management. • Prevention of bedsore.