Surgery for Bowel Obstruction in Governor Pataki
Although none of the authors of Insidesurgery.com have any direct clinical care of Governor George Pataki, the news reports of an additional surgery that was required to relieve a bowel blockage five days after his appendix was removed for appendicitis is something we have experienced in our practice.
Appendicitis is a common condition and affects about 5%-12% of the population in the United States sometime during their lifetime. It can occur in toddlers to the very aged, but is most common in children older than 5 years up to young adolescence. It also seems to have a particularly high incidence in new military recruits, for unknown reasons.
There are two ways appendicitis can occur. The appendix is a blind sac that empties into the last segment of the small bowel called the terminal ileum. This opening can become blocked by fecal material that becomes hardened at the opening (fecalith) or by swelling of lymph tissue around the opening (common cause in children). The mucous in the blocked appendix can not drain, the pressure in the appendix rises, and the pressure inside the slowly filling sac finally ruptures the wall. It usually takes 24-36 hours for the rupture to occur.
Appendicitis has classic findings on clinical exam that will allow an experienced practitioner to make the diagnosis in young, healthy males. However, in younger children, post-menstrual women, and the elderly the diagnosis can be a little trickier as sometimes the patients do not feel any pain. In addition, older people sometimes delay presenting for care as they mistakenly think they are too old for appendicitis.
Once the diagnosis is made, the patient is taken to surgery to have the appendix removed. This is done either laparoscopically or through a relatively small horizontal or slightly oblique incision in the lower quadrant know as a Rocky-Davis incision.
Even in this day of modern antibiotics, it is important to try to take the appendix out before it ruptures. If it has already ruptured, there is an increased amount of swelling and edema of the tissues in the area around the appendix, which lies in the right lower part of the abdominal or peritoneal cavity.
It is this swelling and edema that can cause problems post-operatively. Even a technically perfect operation can, if the appendix has already ruptured, be plagued by post-operative problems. The bowel that lies next to the appendix can become inflamed and have scar tissue or adhesive bands form around it that blocks off flow of air and stool.
If this happens the patient has a distended abdomen, nausea and vomiting, does not report flatus, and has continuing pain. They may also have a fever and an increased white blood cell count. Typically, surgeons try to wait out this period of post-operative inflammation and swelling, especially if it is not severe, as re-entering this area of inflammation can be challenging. However, if the adhesive bands appear to be nearly strangulating the bowel, the surgeon may not be able to wait for the patient “to open up.”
The second surgery to cut the adhesive bands used to be done through an up-and-down, midline surgery called a laparotomy, but is now sometimes also done laparoscopically. The recovery time for this operation is longer if a laparotomy is performed and can be 4-6 days in the hospital and 4-6 weeks of non-strenuos activity afterwards.
Copyright 2006 Insidesurgery.com