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Doc Dutch,
Duodenum was an injury just to the undersurface/edge....single hole in the bottom (I REALLY HOPE!!) and up through head of pancreas. Used "flo-seal" applied right into the pancreatic injury. No obvious fluid coming up c/w major duct leak but that's not good enough. Based on his injuries and wanting to be done this operation I did not cut off the tail to get access to the duct and dye test him and likewise did not go after the ampulla and do a contrast study. I am a fan of post op ERCP if needed and just drained the hell out of it, let my duodenum repair heal then if I get into any problems, let GI do an ERCP and stent or at least do a sphincterotomy to drain it. I took the minimalist route because of the combo of injuries.
No whipple for this boy atleast not on the 1st go round, maybe in a delayed fashion if needed and fully resuscitated, warm, etc......
Out of the unit and getting an UGI with gastroview tomorrow. Out of bed today, already on jejunal tube feeds...I feed everyone within 12-24 hours of becoming 'stable'. His drains so far minimal and sending for amylase in the AM.
Sometimes it's good to be lucky and in this case having the IVC injury be contained and not freely hemorrhaging, I could set it up for potential success.....he's not out of the hospital yet!
1st pic is duodenumm flipped up to injury repair site, had proximal control with vessel-loop but did not open tissue over IVC yet, 2nd on is IVC isolated, gonadal vessels on top ligated and if you look carefully, just superior to the black silk tie is the 1.3 cm repaired lac, vertical orientation
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'Revel in action, translate perceptions into instant judgements, and these into actions that are irrevocable, monumentous and dreadful - all this with lightning speed, in conditions of great stress and in an environment of high tension:what is expected of "us" is the impossible, yet we deliver just that.
(adapted from: Sherwin B. Nuland, MD, surgeon and author: The Wisdom of the Body, 1997 )
Education is the anti-ignorance we all need to better treat our patients. ss, 2008.
The blade is so sharp that the incision is perfect. They don't realize they've been cut until they're out of the fight: A Surgeon Warrior. I use a knife to defend life and to save it. ss (aka traumadoc)
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