The things we see...

Hello,

I'm finally getting around to operating on the older lady with a smooth pelvic mass. I open the belly to find a round, smooth, grapefruit-sized mass sticking out with fingers of omentum and inflammation holding it to the pelvis like a mystic gazing searchingly into her crystal ball.

I slowly peel away the fingers until I find it firmly attached to the colon below. It is obviously filled with fluid; probably an abscess. I take a syringe and needle and aspirate. Yep, pus. Well, this should be easy. I get the suction ready and open up a small hole into the cavity and start slurping the thick, yellow gunk up. Then I start to feel some thicker stuff at the bottom. I pull the suction catheter out and see hair! The abscess is almost emptied now so I enlarge the incision to look inside. I see a golf ball-sized hair ball!

I pull it out and verify that there is no connection to the colon below. I cut off the walls of the abscess, just leaving that part that is attached to the colon and prepare to close.

But, then I remember I should run the small bowel and check the rest of the intra-abdominal contents. As I pull the small bowel out, I notice the proximal part is really distended while the distal part is tiny and shrunken. A bowel obstruction. I follow it along and find that near where the small bowel attaches to the colon it dives into the inflammatory mass in the pelvis where, suddenly, it becomes small. I try to dissect it out but it's a stuck mass. Then stool starts to come out of the sigmoid colon.

So much for nice and easy.

I suck out as much of the stool as I can and it seems to seal itself when retraction is released. I clamp and cut the small intestine on both sides where it enters the inflammation and leave that piece there. I close the part attached to the colon and bring the other side out through the skin on the left. We rinse out her abdomen, leave in two drains, and close up the laparotomy incision. I then suture the small intestine (that I've pulled through the skin to the fascia) and then evert the edges to sew them to the skin creating an ileostomy where the stool can come out so that the friable inflammatory sigmoid can hopefully heal.

Afterwards, Samedi asked me if he and Josue should bring in the next surgical patient. Josue piped up, "After all it's just a SIMPLE hernia."

I laughed. I've learned to never say something will be simple here. The things we see...

James