Abstract text (incl. references and figure legends)
Case history: An 83-year-old woman was brought in by ambulance to the ED with recent onset of epigastric and right upper abdominal pain, reduced appetite and difficulties mobilising. She has a past medical history of left spigelian hernia (4 weeks ago), hysterectomy, 3 umbilical hernia repairs (with mesh), laparoscopic cholecystectomy, hypertension, asthma and left knee osteoarthritis.
Clinical findings: The patient was alert, oriented, afebrile but uncomfortable with tachypnoea, tachycardia but normal blood pressure and SpO2. On examination the abdomen was soft, with generalised tenderness and bowel sounds present.
Investigations/Results: Patient's blood showed mildly elevated CRP but normal WBC and albumin. A CT scan was requested which indicated signs of small bowel (SB) obstruction with a transition point in lower abdomen.
Diagnosis: Adhesional SB obstruction.
Therapy: A nasogastric tube was inserted and a trial with oral gastrografin was tried, but could not be tolerated by the patient. A second attempt failed too. Decision was to proceed with laparotomy. Transition point was found after extensive and difficult adhesiolysis. The SB had several adhesions with the abdominal wall, previous mesh and between bowel loops. Few serosal tears were repaired and few cms of ileum were resected and anastomosed. A drain was placed in pelvis. Patient was transferred to the ITU for post operative care. On the third post operative day, bilous fluid was seen coming around the drain, but not in it. A decision to proceed with second laparotomy identified a perforation of the ileum proximal to the anastomosis. Resection of part of the ileum was performed with a double-barrelled ileostomy. The patient, after a lengthy stay in ITU , was extubated and transferred to the ward.
Comments: This was a challenging case from the operating as well the decision-making point of view of an adhesional SB obstruction post elective hernia repair in an elderly patient with comorbidities.
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