1. Morbidity and Mortality Conference
Section of Trauma
January 2017
Angelica Aliado, MD
Myra Alexandra Firaza, MD
General Surgery Resident

2. R.M., 33/M Admitting Diagnosis Post-operative Diagnosis #1
Wound dehiscence, t/c intraabdominal abscess; ruptured appendicitis with localized peritonitis, s/p appendectomy (1/2/17, JRRMMC)
Post-operative Diagnosis #1
Wound dehiscence secondary to intraabdominal abscess secondary to blown-up stump; ruptured appendicitis with localized peritonitis; s/p appendectomy (1/2/17, JRRMMC)
Procedure #1 Done
Exploratory laparotomy, adhesiolysis, evacuation of abscess, cecorraphy, repair of serosal tear, JP drain (1/11/17, JRRMMC)
Adverse Outcome
Blown-up stump

3. R.M., 33/M Pre-operative Diagnosis Post-operative Diagnosis #2
t/c Repair leak; s/p exploratory laparatomy, adhesiolysis, evacuation of abscess, cecorrhaphy, repair of serosal tear, JP drain (1/11/17); s/p appendectomy (1/2/17)
Post-operative Diagnosis #2
Intraabdominal abscess secondary to repair leak, cecum; s/p exploratory laparatomy, adhesiolysis, evacuation of abscess, cecorrhaphy, repair of serosal tear, JP drain (1/11/17); s/p appendectomy (1/2/17)
Procedure Done #2
Exploratory lapatomy, adhesiolysis, evacuation of abscess, R hemicolectomy (1/15/17, JRRMMC)
Adverse Outcome
Repair leak

4. Background History of Present Illness Past Medical History
Case of acute appendicitis, s/p appendectomy (1/2/17)
Six days prior to admission
(+) purulent discharge per wound site, accompanied by fever and abdominal pain, no BM since post appendectomy
Past Medical History
No HTN, DM
Family History: Unremarkable
Personal and Social History
Unremarkable

5. Background Physical Examination
Awake, not in cardiorespiratory distress
VS BP 120/80, HR 84, RR 20, T 36.7, O2 sat 99%
BMI 22
Pink palpebral conjunctivae, anicteric sclerae
Clear breath sounds, no crackles
Soft abdomen, (+) dehiscence at incision site, (+) tenderness, (+) foul-smelling, fecaloid, purulent discharge
DRE: Unremarkable

6. Background Ancillaries (before 1st reop)
CBC: Hgb 13.3, Hct 38.2, WBC 13.1, Plt 703
Creatinine: 63 umol/L, Sodium 135.5, Potassium 4.12
PT: 13.1 (13.0) INR 1.01, 98% activity
PTT: 32.5 (30.0)
CT 5’00” BT 3’00”
Chest X-ray
Inadequate lung expansion secondary to poor inspiratory effort
Magnified heart vs true cardiomegaly

7. Chest xray

8. Background Intraoperative Findings (1st re-op)
Localized intra-abdominal abscess at the right lower quadrant
Adhesions (non-obstructing) on ileum and cecum
Small and large bowels non-dilated
Blown-out stump
Other structures normal

9. Background Surgical Procedure #1 Post-operative Diagnosis
Exploratory laparotomy, adhesiolysis, evacuation of abscess, cecorrhaphy, repair of serosal tear, JP drain
Firaza/ De Guzman/ Aliado
OR Time: 2:30 hours
EBL: Minimal
Post-operative Diagnosis
Wound dehiscence secondary to intraabdominal abscess secondary to blown-up stump; s/p appendectomy (1/2/17, JRRMMC)

10. Operative pictures

11. D1 Post Re-Op (+) Febrile episodes (Tmax 38.1)
VS BP 120/80, HR 84, RR 20, T 36.5
Abdomen was soft with tenderness on the post-op site
JP 65 cc x 12h, serosanguinous output
NGT: 50 cc, brown-colored output
UO: 0.83 ckh, clear
Still on NPO. IV Cefoxitin was continued. Pain medications (Tramadol drip, Ketorolac IV, Morphine IV) started. TPN started

12. D2 Post Re-Op No hypotension, (+) febrile episodes (Tmax 38.1)
No vomiting, no DOB
No flatus yet
(+) post-op site pain
VS BP 120/70, HR 94, RR 20, T 37.8
Slightly distended abdomen, well-coapted wound, with moderately soaked dressing
UO 0.5ckh x 24h
JP 60 cc x 24h
NGT 230 cc, 24h
Septic work-up done (blood c/s, urine g/s, c/s, wound g/s, c/s)
Shifted Cefoxitin to Piperacilllin-Tazobactam, Metronidazole, analgesics and TPN continued

13. Ancillaries (before 2nd reop)
CBC: Hgb 11.9, Hct 34.8, WBC 20.87, Plt 519
Creatinine: 72 umol/L, Sodium 134, Potassium 3.81
Chest X-ray: no significant chest findings
Plain abdomen:
Dilated bowel loops with multiple air-fluid levels, presacral gas present, interserosal spaces not thickened
t/c intestinal obstruction

14. Plain abdomen xray

15. D3 Post Re-Op No febrile episodes/vomiting (+) flatus, (-) BM
VS BP 110/80, HR 92, RR 20, T 36.8
Slightly distended abdomen, (+) seropurulent discharge on wound site, (+) tenderness
Shifted Piperacillin-Tazobactam to Ciprofloxacin (culture-guided), Metronidazole, analgesics and TPN continued
A: Repair leak
P: ‘D’ Exlap

16. Background Intraoperative Findings (2nd re-op)
Localized right lower quadrant abscess collection
Repair leak at cecum
Multiple dense adhesions
Dilated small bowels

17. Background Surgical Procedure #2 Post-operative Diagnosis
Exploratory laparotomy, adhesiolysis, evacuation of abscess, right hemicolectomy, JP drain
Firaza/ De Guzman/ Aliado
OR Time: 5:15 hours
EBL: 700 cc
Post-operative Diagnosis
Intra-abdominal abscess secondary to repair leak, cecum; s/p exploratory laparatomy, adhesiolysis, evacuation of abscess, cecorrhaphy, repair of serosal tear, JP drain (1/11/17)

19. Operative pictures

20. D1-3 Post 2nd Re-Op No hypotensive episodes, no febrile episodes
BP 130/80, HR 70, 21, T 36.8
Clear breath sounds
Soft, non-distended abdomen
Wound well-coapted with no purulent discharge
NPO
IV antibiotics continued
NGT, JP, IFC maintained

21. D4 Post 2nd Re-Op No febrile episodes/vomiting No DOB
(+) flatus, (-) BM
Minimal post-op site pain
BP 120/80 HR 72 RR 20 T 37.0
Clear breath sounds
Soft abdomen with well-coapted wound with no purulent discharge
Diet progressed (CLGL)
NGT, IFC removed (D4)

22. D5 Post 2nd Re-Op No febrile episodes, no vomiting (+) BM
Normotensive, normal heart rate
Diet progressed (Soft diet)

23. D6 Post 2nd Re-Op No febrile episodes, no vomiting (+) BM
Normotensive, normal heart rate
Soft abdomen, well-coapted wound with moderately soaked dressing, serosanguinous
JP: 39 cc serous, removed
Diet progressed (DAT with SAP)
Shifted all medications to oral (Ciprofloxacin, Metronidazole and Celecoxib)

24. D7 Post 2nd Re-Op Afebrile (+) BM, flatus Soft non-distended abdomen
May go home