Sunday, December 14, 2008

Jejunum Rupture

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Jejunal Rupture

The diagnosis of blunt small bowel rupture is suspected when abdominal tenderness, pneumoperitoneum or a positive DPL is present. Extravasation of contrast material during computed tomography (CT) scanning is rare. When free fluid is detected in the abdomen by CT scan without a solid organ injury, a hollow viscus injury should be suspected.
Injury to the small bowel is evaluated intraoperatively by “running the bowel”: the small bowel and its mesentery are inspected in a systematic and comprehension fashion from the ligament of Treitz cauded to the ileocecal valve. As active mesenteric bleeding is ancountered, it is controlled by isolation and individual ligation of the bleeding vessels rather than by mass ligation of the mesentery, which may produce ischemia. Likewise, as bowel perforation are found, temporary control measures are rapidly initiated in an effort to prevent excessive or ongoing soilage. Once all bowel injuries are accounted for, the decision must be made whether to perform primary repair, resection of the injured segment, or some combination of the two. Primary repair of multiple injuries preserve bowel length and is generally preferred. At the discretion of the operating surgeon, resection of a segment containing multiple injuries may be performed to expedite the operation, provided that the amount of bowel to be resected is small enough that its loss would have only a negligible effect on digestive function.

Management of each individual wound is determined by its severity according to the AAST grading system. Small partial-thickness injuries (grade I) are managed by reapproximating the seromuscular layers with interrupted sutures. Small full-thickness wounds (grade II) are repaired with limited debridement and closure. Closure is performed in either one or two layers (we prever a two layers closure), and transverse closure is preferred to avoid luminal narrowing. Large full-thickness wounds (grade III) may be repaired primarily if luminal narrowing can be avoided; otherwise, resection and anastomosis should be performed. Extensive wounds and wounds associated with devascularization (grade IV and V) are treated with resection and anastomosis. When mesenteric injury is encountered in the absence of bowel injury, the associated bowel must be closely assessed for evidence of vascular compromise. If the bowel appears viable, the rent in the mesentery should be reapproximated after bleeding is controlled to prevent an internal hernia. If there is evidence of vascular compromise, bowel resection and anastomosis are indicated.

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