#laparotomy

[steampunk-llama]

Surgery Andy

[ijcimr]

Combined cervical laceration and bladder rupture: a case report of an unusual complication of precipitated labor by Dr Fatemeh Darsareh in International Journal of Clinical Images and Medical Reviews 

Abstract

Cases of bladder rupture have been rarely reported following vaginal childbirth. To the best of our knowledge, however, no cases of combined cervical laceration and bladder rupture have been reported to date. We present the first case of a 31-year-old woman with gestational diabetes who suffered a combined cervical laceration and bladder rupture after childbirth. Precipitated labor caused by oxytocin induction resulted in vaginal and cervical lacerations. The bladder rupture was confirmed by cystography. A team of obstetricians and urologists performed the laparotomy. The patient was kept under observation for two weeks before being discharged with no serious complications.

Keywords: Bladder rupture; Cervical lacerations; Precipitated labor; Childbirth trauma; Case report.

Introduction

Spontaneous bladder rupture following normal vaginal delivery is a surgical postpartum emergency. Previous cesarean section, vacuum/forceps-assisted vaginal deliveries, and distended bladder compressed by engaged head in birth canal are all risk factors for bladder injuries in healthy parturient women 1. Cases of bladder rupture, accompanied by uterine rupture, have been rarely reported following vaginal birth after cesarean section 2. To the best of our knowledge, however, no cases of combined cervical laceration and bladder rupture have been reported to date. We present the first case of spontaneous bladder rupture with cervical laceration after a precipitated vaginal delivery.

Case Presentation

A 31-year-old, G2P1L0D1, woman with gestational diabetes, was admitted to our maternity ward at 38 weeks of pregnancy for elective induction of labor to terminate her pregnancy.  She had a history of preterm birth and was a known case of minor thalassemia. The induction of labor began at 5:00 a.m. with oxytocin, and contractions began approximately two hours later. Table 1 depicts the progress of labor. During her labor, the patient urinated once. Finally, at 10:40 a.m., she gave birth to a baby boy weighing 3700 grams with an Apgar score of 7/9.  Excessive vaginal bleeding was observed following placental expulsion. The examination revealed an extensive laceration in the vagina and cervix that was repaired by the obstetrician and midwife. The patient was catheterized and was being closely monitored. A urologist was consulted due to the oliguria and hematuria (100 cc output with gross hematuria within 5 hours of childbirth). Cystography, as recommended by the urologist, revealed the bladder rupture. The patient was prepared for a laparotomy immediately. The laparotomy was performed by a team of obstetricians and urologists. Several hematomas were discovered in the uterine body and the broad ligament that the team decided not to manipulate because it did not grow during the surgery. A bladder rupture was found at the dome of bladder that was repaired in two layers. One pack cell unit and two FFP units were transfused. A peritoneal drain was placed posterior to the bladder and the skin incision was closed in layers. The patient was observed for two weeks. The result of the ultrasound revealed the shrinking of the hematoma. The blood and renal tests were normal. The catheter was removed after 2 weeks and the patient was discharged.

Table 1: The progress of labor

Discussion

Precipitate labor is defined as the expulsion of the fetus within three hours of the start of contractions. Few studies have found that precipitated labor is harmful to both the mother and the newborn. Precipitated labor, which is most commonly associated with placental abruption and induction of labor, is a significant risk factor for maternal complications 3. Maternal morbidities reported included extensive birth canal lacerations, uterine rupture, placenta retention, the need for revision of uterine cavity, post-partum hemorrhage, and blood transfusions 3,4. The lower urinary tract's anatomic proximity to the reproductive tract predisposes it to iatrogenic injury during obstetric procedures. The bladder and lower ureter are two of the most commonly involved organs. Because the dome of the bladder is the weakest area, most bladder ruptures occur through the peritoneal cavity 5. In our case, in addition to deep vaginal tears and extensive cervical laceration, bladder rupture occurred, but the diagnosis was delayed by a few hours. Given the nonspecific clinical features of bladder rupture, the diagnosis should be approached with caution. Oliguria and gross hematuria after a traumatic childbirth increase the likelihood of bladder rupture. In such cases, a cystogram is thought to be the best method for early detection.

In our case the patient had induced labour with oxytocin. The use of oxytocin to induce labour can result in tachy-systole and thus shorter deliveries. So in our case we believe that the power of uterine contractions and quick descent of passenger (3700 grams fetus) were the main risk factors of precipitated labour and the complications accompanied with it. A distended bladder during labor, particularly in our case, where the fetus descended quickly, could also be a factor in bladder rupture. Although the patient urinated normally during labor, it was critical to ensure that the bladder was empty, especially during the active phase of labor, to avoid bladder damage.

CONCLUSIONS

Bladder and cervical rupture should be considered, after precipitated vaginal delivery. When there is gross hematuria, a urinary catheter should be inserted to monitor the hematuria and urine output. If the hematuria persists and other associated symptoms appear, cystography is a useful tool for determining the severity of the bladder injury and determining the cause.

Funding

This study received no specific funding from public, commercial, or not-for-profit funding agencies.

Conflict of Interest

Authors had no conflicts of interest to declare.

Patient consent

Obtained.

For more details: https://ijcimr.org/editorial-board/ 

[jcmicr]

Spontaneous Rupture of Wandering Spleen: Case Report by Mina Alvandipour in Journal of Clinical and Medical Images, Case Reports

Abstract

Keywords: Spleen; wandering spleen; ectopic spleen; splenic rupture.

Introduction

A wandering spleen is a rare clinical occurrence with fewer than 500 cases reported and an incidence of less than 0.2% [1]. wandering spleen is caused by either extreme laxity or absence of the normal ligaments that anchor the spleen to the left upper quadrant. Gravity also plays a role by allowing the spleen to descend into the lower abdomen attached by its vascular pedicle [2]. Symptoms depend on the degree of torsion and range from chronic abdominal pain in mild torsion to acute pain in severe torsion and infarction. Accurate clinical diagnosis is difficult because of the rarity of the condition and non-specific symptoms. Radiological evaluation includes usage of ultrasound, Doppler, abdominal CT or MRI depending upon availability or preference [3]. A wandering spleen can be either congenital or acquired. In the congenital condition the ligaments fail to develop properly, whereas in the acquired form the hormonal effects of pregnancy and abdominal wall laxity are proposed as determining factors .However, the precise etiology of the wandering spleen is not known [1]. We present a spontaneous rupture of a wandering spleen with severe torsion and infarction and abdominal pain without any history of trauma.

Case Report

A 25 years old female present to emergency unit with 2 week history of progressive abdominal pain, recurrent constipation ,vomiting and loss of appetite. There was no history of melena, fever, and hematochezia and weight loss. On examination there was periumbilical and epigastria tenderness and a firm and tender mass in the right side of the abdomen without muscle guarding and rebound tenderness. The vital sign and laboratory results were all within the normal ranges, except decreased hematocrit (hemoglobin-8.4). The plain abdominal radiograph was un-remarkable while abdominal ultrasonography with color Doppler showed absence of spleen in its normal location in the left upper abdomen. Also it detects a heterogeneous hypoechoic capsulated mass with diameter of 175mm in right lower abdomen. Other organs of the abdomen were normal. Abdominal pelvic CT scan with and without contrast was recommended and findings was Absence of the spleen in its normal position in the left hypochondrium, and presence of large diameter mass (splenomegaly)in the right sub hepatic area(Wandering spleen) . Other organs of the abdomen were normal. Contrast-enhanced computed tomography (CECT) of the abdomen revealed whirlpool sign near the umbilicus. The splenic parenchyma showed abnormal enhanced areas, suggestive of splenic torsion and infarction.

A final diagnosis was wandering spleen with torsion of the vascular pedicle and infarction. The patient underwent a total splenectomy. During the laparotomy, an enlarged and infarcted mass was seen in right side of abdomen. The characteristic “whirlsign” can be seen in the area of the splenic vascular pedicle, indicative of torsion. Histological examination confirmed total infraction of the wandering spleen. The postoperative course was uneventful, and the patient was discharged on the 4th day after the operation.

Discussion

A wandering spleen is a rare but well-known entity. The incidence is < 0.2%. It is more common in females than males between the second to fourth decade of life and children [4]. Splenic weight >500 g in more than 8 out of 10 cases [5]. Interestingly, it has been reported that one out of three cases of wandering spleen appears in children bellow the age of 10 years old [7].

Wandering is characterized by splenic hyper mobility that results from elongation or mal-development of its suspensory ligaments. It is also known as aberrant, floating, displaced, prolapsed, ptotic, dislocated or dystopic spleen. Ectopic spleen, splenosis and accessory spleens are separate clinical entities and must be distinguished from it [5]. If the pedicle is twisted in the course of movement of the spleen, blood supply may be interrupted or blocked, resulting in severe damage to the blood vessels .Acute splenic torsion compromises venous outflow, which causes congestion and impairment of arterial inflow. Pain is originated from the splenic capsular stretching with rapid splenic enlargement and localized peritonitis [6]. Etiology is congenital or acquired. In case of congenital anomaly, a failure occur in fusion of the dorsal mesogastrium with the posterior abdominal wall during the second month of embryogenesis. Acquired risk factors that predispose to wandering spleen include pregnancy, trauma and splenomegaly [7]. Splenic torsion is usually clockwise. Complications of splenic torsion include: gangrene, abscess formation, local peritonitis, intestinal obstruction and necrosis of the pancreatic tail, which can lead to recurrent acute pancreatitis [8].

Wondering spleen had nonspecific symptoms such as abdominal pain that make diagnosis extremely challenging. As a result, radiologists play a major role in the diagnosis of this condition and its complications. Torsion may occur acutely and present with infarction or peritonitis. Chronic intermittent torsion can lead to pain, splenomegaly, and functional splenectomy. Contrast-enhanced computed tomography (CT) is the best imaging tool to make this diagnosis, although ultrasound may be used as well. Imaging findings on CT include identification of a spleen in an abnormal location, or with an abnormal orientation in the left upper quadrant. Often the wandering spleen is identified as a “comma” shaped mass in abdomen, with no normal left upper quadrant spleen [9].

Laboratory investigations are non-specific. Thrombocytopenia, through a mechanism of spleen enlargement secondary to compression of the splenic pedicle is rarely found [7]. The clinical presentation of wandering spleen is variable; it is either asymptomatic or noted incidentally during physical and radiographic examination or presents as acute abdomen due to torsion with subsequent infarction. The most common presentation is a mass with non-specific abdominal symptoms or intermittent abdominal discomfort due to congestion resulting from torsion and spontaneous detorsion [10]. Today, the only recommended treatment for wandering spleen is operation [7]. Splenectomy is indicated for infracted spleen and sometimes for huge splenomegaly precluding splenopexy. Splenopexy is the choice of treatment if the spleen is not infarcted [6]. Splenic preservation is highly recommended for young patients—those under one year of age up to those in their thirties—who are at particular risk for overwhelming post-splenectomy sepsis [10]. This should be appropriately followed up by the prophylactic vaccines against post-splenectomy sepsis syndrome. Ideally they should be administered before surgery; however, in emergencies this is not always possible [1].

Conclusion

In this case, splenectomy was done due to spleen infarction. Laparotomy was done in this case because of low experience at laparoscopy splenectomy. This report highlights the investigations and management necessary for a patient who presents with an ischaemic torted wandering spleen.

Acknowledgement: None.

Conflict of Interest: None.

Funds: None.

For more details : https://jcmimagescasereports.org/author-guidelines/ 

[meteortrails]

will say, weird that everyone thinks Tim would have an actual splenectomy scar?? like if we’re thinking traditional surgery scars in western medicine, he’s almost definitely got a laparotomy scar. Tim’s bleeding out on the table, there’s no way they had time to do scans to identify which organs got damaged or make any sort of accurate external assessment; that kind of situation, you’re just gonna cut the whole abdomen open bc how else are you even gonna know what needs to be fixed/removed?? so Tim probably has a semi-neat little line down his belly once he’s all healed up, which coincidentally is a vague enough surgery scar that he can tell All Sorts of lies about it, which I think he would do purely for the fun of it.

[nixiecat]

is that a scar on your tummy if so hnnnng *gets so hard she passes out*

sorry to inform you that it is unfortunately just a weird trick of the light and not a super rad scar

[neuromedical]

I'm sure sex is fun and all but have you ever done a peripheral nerve block and when they started operating the patient didn't feel a thing?

Euphoric.

[themanwhowouldbefruit]

everyone in the goddamn world was able to get laparoscopic bullshit done. good for fucking you!!!!!!! you assholes!!!!

[strawberri-syrup]

medical terminology exam tomorrow..........i am so cooked

[maryjocs]

.

[citronaut69]

I think my career as an RN in the middle of the worst of C19 on a med/surg unit plus now working a vascular/thoracic PCU/ICU has desensitized me to so much weird and traumatizing shit

[surgeine-blog]

The Laparotomy Procedure Packs are specially designed for various general types of surgical procedures in the operating room. These products offered by us are developed using superior quality raw material in accordance with #international medical standards. Our products are hygienic and are well appreciated in the market for their durability.

[marketresearchtrendsandinsights]

https://joyrulez.com/blogs/199905/Global-Laparotomy-Sponges-Market-Size-Overview-Key-Players-and-Forecast

[love-bugsy]

the worst thing about love is… | jason todd (chapter 1)

you’re just trying to get through your surgical residency, but this masked vigilante keeps showing up half-dead on your fire escape and reminding you of your dead best friend. oh well, at least he's cute.

tw: stitches, mentions of blood and injuries, swearing, completely ooc Jason but he’s like my own lil character now and I’m protective, very inaccurate medical terminology and procedure lol

only jerks steal other people's writing (just don't repost, mate)

There’s a dead man on your fire escape.

Well. He’s not actually dead, but his pulse is weak when you drag him into your living room, out of the relentless Gotham rain. Pulling your hand away from under his mask, you crouch down, peeling off the worn leather jacket around his shoulders and unbuckling his pauldrons. You feel around his back, brows furrowed. You can’t feel anything through the padding in his rain soaked shirt.

Hands wandering down to where his front is flat on the floor, you press down on his side, eyes widening when your fingers come back slick with blood. You go into autopilot, flipping him onto his back and yanking up his compression shirt. You might’ve gasped at the knife wound if you weren’t working on instinct. It’s bad. 

Shoving away the doubt clawing at the base of your skull, you steady your trembling hands. You’ve been trained for this. 

Don’t feel, just do.

The cut is long and serrated, and deep as all hell. It slices through the middle of a jagged, Y-shaped scar that chains over his shoulders like a noose. Jesus. 

It’s like he was stabbed and then dragged across the floor, cutting diagonally across his torso. How is he even still alive? Your hands move faster than you can think, completing an internal checklist as you go.

Breathing? Fast and shallow through his modulator, no obstructions. Bleeding? Applied tourniquet to epigastric region - transfusion isn’t even an option… Your brain works overtime, sifting through diagnostics lectures - penetrating abdominal trauma, debrided of devitalised tissue, no visible debris… You trace the edges of the wound looking for inflammation or fluid buildup; signs of peritonitis, but the weapon seems to have missed any internal organs. Lucky. Even luckier that he landed on a surgical resident’s fire escape.

Reaching over to the lamp by your couch, you shift it so that it shines directly over his abdomen. A last check of his wound confirms that there are no external indications that you should conduct a laparotomy. You just have to sew him up and hope to god the knife didn’t puncture anything internal.

You keep a hand planted firmly over his tourniquet, applying constant pressure, reaching for your backpack. Dragging it over, you use your teeth to open your suture kit and your free hand to sterilise his cut with Betadine and alcohol, wiping gentle circles outward from the wound. You dip your needle like Achilles in the Styx, hand and all, into the sterilising liquid, tugging a glove on with your teeth. 

You grip the needle driver in your dominant hand, pickups clutched in the other and take a steadying breath. There’s a stillness to the room, quiet save for your heartbeat pounding in your ears. The wound is large - high tension - so… mattress sutures… horizontal so the tension is spread over the edge of the wound. 

You take your first bite, adrenaline driving your needle into a clean stitch. You reverse it, passing through his cut again, before tying it off with the practised motions of a thousand surgical knots tied on yarn and thread and fraying jeans. You settle back on your knees after the first suture, readying yourself for the stitching to come, and start the next one.

~

Hours later, you haul him onto your couch, sitting him up on the arm rest to take pressure off of his dressed stitches. Frowning deeply at how uncomfortable he looks - even unconscious, you tuck a throw pillow under his scuffed metal mask. 

Leaning close to check his breathing, you hear crackling slow and deep through the helmet’s voice modulator. Bone-deep relief floods your system, a little sigh leaving your mouth involuntarily. Sitting heavily against your coffee table, you press the heels of your hands into your weary eyes. 

He’s stable. For now at least. 

Head bumping against the edge of your couch, you breathe in deeply, fighting the anxiety twisting in your ribcage. The couch smells like rubbing alcohol, stinging your nose so badly your eyes water. It’s followed by something familiar - underneath the heady scent of petrol and metal - like… if you mixed Gotham up into a single smell; rain and smoke and wet pavement. He… he smells like-

“Jay!” 

The faulty fluorescent lights - courtesy of your parent's small family diner - seem to flicker in tandem with your strident yell.

Your best friend looks up at you through a mop of dark hair, collarbones poking out of his thin t-shirt, second-hand leather jacket chucked haphazardly on the other side of the booth. He’s stolen your copy of Jane Eyre, flattened with one hand next to a plate of old fries you’d scrounged for him.

You tug your book from his grasp, tucking your pen into the pocket on your apron. He looks up at you with a mouth full of fries, infuriating confusion written across his face.

“What? You promised I could read it.” You sigh in exasperation.

“When I’m finished! And-” A dramatic gasp rips from your mouth when you examine the book. “Are these- grease stains?” You take the book in both hands, swatting Jason with it.

“What so it’s okay to hit me with a book but not get grease- fuck, jesus, okay, okay!” You raise the book over your shoulder with both hands.

“Do you yield?” His mock-angry expression almost makes you laugh, a hand held up near his face to shield from your attack. There’s a soft twist to his frown, like he’s trying to stop his mouth from pulling into a grin. He raises his hands in surrender, and you relax your hold on the book.

Rookie mistake.

Jason darts forward, faster than you can blink, grasping your waist with both hands and dragging you towards him. He yanks the book from your hands and lets you go, grinning childishly at you with the book in his hands. The cat with the canary.

You throw your hands up in exasperation before planting them on your hips like a disappointed mother. The admonishment on the tip of your tongue turns into a weary sigh when you hear your parents calling for you from the diner kitchen. “Fine. But you actually have to try to not spoil it this time.”

Jason crosses his fingers over his chest, “Scout’s honour, birdie.” 

You try not to flush at the nickname, just like you do every time he says it. Still, you fold like a stack of cards.

(He spoils it the next day.)

~

When you wake two hours later for rounds (at the ass-crack of dawn), he’s already gone. You pad quietly around your kitchen making coffee from day-old grounds, cautious not to disturb the sanctity of the early morning (or the ghost of his presence).

The only evidence of him is alight in the dim light that spills over your kitchen counter and into your living room - the deep indents in your couch and the bloodstains on your carpet… The rain on your wood floors, from the fire escape window you’re sure you didn’t leave open.

hi, hello, uhh this is the first fic I've ever posted so bear with me. if anyone actually sees this, i do apologise for the inaccuracies and lengthy prose. also, this will be a series so stick around if you like slow updates, slowburn and second chances. thanks for reading my rambles.

with love, bugsy

[crippled-peeper]

I don’t think having to have an exploratory laparotomy because your intestines are destroying themselves is the behavior of an abled person trying to infiltrate your rare disease club

[random-brushstrokes]

Vicent Castell i Domènech - Laparotomy (1898)