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11 Surgical Decision-Making in Complex Clinical Scenarios in Abdominal Surgery: A Case-Based…
123
Can Burst Abdomen BePrevented?
Preventive measures in the initial laparotomy
play a crucial role in averting the occurrence of
burst abdomen. Employing mesh during emergent laparotomies can preempt future fascial
dehiscence, particularly in cases where there are
concerns regarding weak fascia or infection risks
are high [54]. Additionally, employing longlasting monolament sutures in a running technique during primary fascial closure has been
shown to reduce incisional hernia rates compared
to interrupted suture techniques [58].
The Management
In managing the burst abdomen, emergent reclosure in the operating room remains the cornerstone. The eviscerated abdominal contents should
be washed with warm saline and returned to the
abdominal cavity.
The choice of closure technique and the timing of closure is a crucial surgical decision. The
current evidence favors fascial closure reinforced
with mesh [59], which results in lower incisional
hernia rates (12.5%) compared to primary suture
closure (30.7%) [54, 59]. The mesh reinforcement has similar outcomes in terms of surgical
site infection, recurrence, and mortality rates
[59].
We prefer use of biologic mesh reinforcement,
placed in the retro rectus space and complex
abdominal wall reconstruction [8]. In the case of
a burst abdomen, utilizing size 0 polydioxanone
(PDS) suture material in a running fashion with
each bite encompassing the entire abdominal
wall excluding the skin and subcutaneous tissue
has been shown to effectively prevent recurrent
dehiscence [60]. Each bite should be 3cm from
the fascial edge and should travel no more than
5mm creating a wound-suture ratio of 1:10 [60].
Summary
The management of burst abdomen represents a
rare but a great challenge in acute care surgery.
Burst abdomen, characterized by the breakdown
of surgical incisions, poses signicant challenges, with mortality rates reaching 40% and an
incidence of 1% within 30 days postoperatively
(Fig.11.14). The closure technique of burst abdomen should include mesh reinforcement, placed
in the retro rectus space, but the timing is based
on the edema and present of contamination level.
If there is signicant edema present, we prefer
use of DPR (Fig.11.15) and temporary closure
for 48–72 hours [45], followed by CAWR
(Figs.11.16 and 11.17).
Fig. 11.14 Ischemia of the ileostomy and severe wound
infection due to intra-abdominal process. (Courtesy of Dr.
Lati)
124
T. Rosing and R. Lati
Fig. 11.15 Illustration of a patient undergoing DCL and
DPR (Fig. 11.15). Temporary abdominal closure with
DPR.Blake drain (not seen are placed for DPR, one on
each side of superior abdomen, with nal CAWR with
biologic mesh) (Figs.11.16 and 11.17). (Courtesy of Dr.
Lati)
Fig. 11.16 Illustration of a patient undergoing DCL and
DPR (Fig.11.15), with nal CAWR with biologic mesh
(Figs.11.16 and 11.17). Tailored biologic mesh size for
CAWR. (Courtesy of Dr. Lati)
Fig. 11.17 Illustration of a patient undergoing DCL and
DPR (Fig.11.15), with nal CAWR with biologic mesh
(Figs. 11.16 and 11.17). Ensuring that biologic mesh is
placed appropriately for proper coverage. (Courtesy of Dr.
Lati)
11 Surgical Decision-Making in Complex Clinical Scenarios in Abdominal Surgery: A Case-Based…
The Dicult Hernia Repair
Patient Example 8
Patient is a 47-year-old male with past medical
history of obesity, hypertension, and GERD who
presents to the emergency department with
abdominal pain. Patient states that he has had an
abdominal hernia ever since he underwent an
exploratory laparotomy 1 year ago for GSW to
the abdomen. He underwent two explorations
and incomplete lysis of adhesions, and on the last
exploration several years ago, the surgeon found
a hostile abdomen and decided to bell out and
declared that “abdomen was not operable.” He
has had multiple visits to the emergency department since then and refused to be operated on,
the last one being two weeks prior to this visit.
On CT scan patient has a large ventral hernia
containing most of his small bowel. You evaluate
the patient and note that the hernia is tender to
palpation with erythematous skin changes. This
time he agrees to let you take the patient urgently
to the operating room. Diagnosis: Neglected ventral hernia.
Fig. 11.18 Large neglected abdominal wall hernia on a
patient that was seen by many surgeons, but was not operated because he did not have obstructive symptoms!
(Courtesy of Dr. Lati)
125
Identication andDiagnosis
“Ventral hernia is a surgical disease, should be
treated surgically, and one should die from it”–
the senior author wrote in recent years on one
editorial [61], but the timing and optimal repair
technique intervention continue to be debated. In
the context of strangulated hernias, reduction
should be abstained from to prevent the introduction of compromised or necrotic bowel segments
into the peritoneal cavity, potentially leading to
diffuse peritonitis [62], and the patient should be
operated on at once. The discomfort caused by
neglecting it is obvious as illustrated in a 77-yearold male patient (Fig.11.18) that was “shopping”
for a surgeon for years but was refused, because
he was “not symptomatic enough,” and “he
would die on the table.” He did very well with a
new abdominal wall. Another group of patients
with hernia that are often neglected by surgeons
are those with ascites due to cirrhosis (Fig.11.19).
Fig. 11.19 Large neglected umbilical hernia in a patient
with severe liver cirrhosis awaiting liver transplant. This
patient underwent complex abdominal wall reconstruction with much improved quality of life, and about 6
months later, he received a liver transplant. (Courtesy of
Dr. Lati)
Management oftheDisease
Preoperative considerations, including comorbidities and hernia complexity, are pivotal in determining the management of difcult hernias. With
the prevalence of ventral hernias increasing annu-
126
T. Rosing and R. Lati
ally, there is equal increase in recurrent rates status post-initial repair, ranging from 15% to 40%.
These rates necessitate careful evaluation of preoperative risk factors such as BMI >30, smoking,
diabetes, COPD, American Society of
Anesthesiologist (ASA) Grades III–IV, and steroid use [63]. Having a preoperatively high risk of
recurrence indicates that patients are subjected to
major surgery with the potential of no long-term
benet. While ventral hernia repair for elective
cases may benet from preoperative medical optimization, emergency scenarios require immediate
surgical intervention despite the associated risks.
The decision between open and laparoscopic
approaches for ventral hernia repair has been rigorously debated. While an open approach is the
mainstay for emergent repair of strangulated bowel,
contemporary trends favor more minimally invasive approaches, supported by studies demonstrating reduced hospital stays, decreased chronic pain,
and fewer analgesic requirements [64]. Current
evidence suggest considering a laparoscopic
approach for hernias <10 cm in width and in
patients with morbid obesity, diabetes, and immunosuppression [64]. However, larger and more
complex hernias benet from open repair, most
notably in cases requiring complex abdominal wall
reconstruction. This involves utilizing component
separation techniques which divide the myofascial
layers to alleviate midline tension and facilitate
midline closure [65]. While there is a broad array
of mesh to choose from, ranging from permanent
synthetic to absorbable synthetic and biologic,
mesh selection is inuenced by factors such as hospital inventory, surgeon preference, and the contamination level. In summary, while minimally
invasive techniques have a modern role in ventral
hernia repair, more complex and larger diameter
hernias may necessitate an open approach utilizing
component separation and complex abdominal
wall reconstruction with mesh reinforcement.
A 58-year-old male with obesity, hypertension,
congestive heart failure (CHF) from an unknown
etiology, and a pacemaker presented with deteriorating overall condition secondary to groin and
scrotal pain related to a long-standing left inguinal hernia. Following years of the hernia being
present, sudden onset swelling and pain in the
left groin, and inability to reduce the hernia, he
presented with hemodynamic instability and
severe leukocytosis, and overall “real-sick look.”
CT scan imaging done prior to surgery team con-
sultation uncovered an incarcerated left scrotal
hernia containing the sigmoid colon. Upon evaluation by the surgical team, the patient not only
had a strangulated inguinal hernia, but he also
had a NSTI of the scrotum (Fig. 11.20).
In light of the patient’s deteriorating hemodynamic status and unstable cardiac condition, an
emergent exploratory laparotomy was undertaken to reduce the sigmoid colon. The reduction
of the sigmoid colon and return to the abdomen
was performed with many difculties (Fig.
Management ofIntraoperative
Surprises inAcute Care Surgery
Patient # 9
Fig. 11.20 Scrotum of the patient with NSTI secondary
to incarcerated, non-reducible left colon into the scrotum,
and neglected for at least 7 days. (Courtesy of Dr. Lati)
11 Surgical Decision-Making in Complex Clinical Scenarios in Abdominal Surgery: A Case-Based…
Fig. 11.22 A segment of small bowel with three lesions
of endocrine tumor. (Courtesy of Dr. Lati)
127
Fig. 11.21 Incarcerated left colon in the left scrotum,
pulled out of the scrotum from the abdomen. (Courtesy of
Dr. Lati)
11.21). Intraoperatively, he developed signicant
hypotension and desaturation requiring ambo
bagging and high doses of vasopressors, necessitating a swift transition to a damage control
laparotomy and wide incision and debridement
of the scrotum with placement of wound VAC
both in the abdomen and scrotum, followed by
surgical intensive care unit (ICU) admission for
resuscitation.
Second-Look Procedures
The challenging nature of the case became further pronounced during second-look procedures,
where intraoperative exploration revealed
unforeseen white plaques on a 45cm segment of
small bowel, prompting a resection with primary
anastomosis (Fig. 11.22). The identication of
cirrhotic changes in the liver and an edematous,
partially necrotic and calcied gallbladder (Fig.
11.23) prompted a partial cholecystectomy. A
matted hepatocytic triangle during cholecystectomy posed additional unforeseen challenges
leading to a reconstituted subtotal cholecystectomy. Additionally, an appendectomy was per-
formed due to the presence of large fecaliths in
the appendix which further underscored the
theme of unexpected ndings that highlight the
complexity of this case. Multiple trips to the operating room were required including near completion of the cholecystectomy on the third
exploration (Fig. 11.10) followed by meticulous
wound management and wound VAC placement.
Pathology reports unveiled a welldifferentiated neuroendocrine tumor in the small
bowel segment, creating a new dimension in the
patient’s diagnostic journey. Elevated biomarkers
such as plasma chromogranin A and serum serotonin levels pointed toward neuroendocrine
tumor activity, introducing a new realm of complexity into the management plan. Additionally,
pathological examination of the gallbladder and
appendix uncovered chronic cholecystitis, cholelithiasis, and acute inammation of the appendix,
contributing further to the intricate nature of the
case. Eventually we were able to save both of his
testicles (Fig. 11.23) and close the scrotum and
the abdominal wall. He was discharged from the
hospital in very good condition (Fig. 11.24).
Management of unexpected ndings in the operating room both electively but particularly in emergency surgery or acute care surgery often requires a
change in operative planning and adaptation to a
128
Fig. 11.23 Viable testicle following multiple debridement of scrotum for NSTI. (Courtesy of Dr. Lati)
Fig. 11.24 Scrotum closed. Full recovery. Closed scrotum from Fig. 11.23. Patient had no complications and
made a full recovery. (Courtesy of Dr. Lati)
new environment and pathology. Despite meticulous preoperative planning and thorough imaging
studies, unforeseen intraoperative surprises can
present formidable challenges that demand immediate attention and innovative solutions. Surgeons
must maintain a high level of vigilance and readi-
T. Rosing and R. Lati
ness to navigate through unanticipated discoveries,
ranging from anatomical variations and hidden
pathologies to unforeseen complications arising
from the patient’s unique physiological response to
surgery. These surprises test the surgeon’s expertise,
decision- making skills, and the ability to think
swiftly and strategically under pressure.
The ability to adeptly handle intraoperative
surprises is a hallmark of surgical mastery, signifying a surgeon’s capacity to pivot and adjust surgical strategies in real time to safeguard patient
well-being. Whether encountering unexpected
anatomical variations, unforeseen pathology, or
unanticipated bleeding, surgeons must demonstrate adaptability, resilience, and quick thinking
to ensure optimal outcomes for their patients.
The art of surgical decision-making lies not only
in meticulous planning and technical prociency
but also in the surgeon’s capacity to remain calm,
focused, and proactive in the face of unexpected
challenges that may arise during the course of a
surgical procedure. Embracing these surprises as
opportunities for growth and learning, surgeons
navigate through uncharted territory with skill
and nesse, showcasing the dynamic and everevolving nature of the surgical art.
The above case that authors dealt with recently
illustrates best such unexpected surprises. The
case of the patient with a complex medical history
and unfolding obstacles represented major challenges requiring new adaptation, such as small
bowel resection, partial open cholecystectomy,
initiation of DPR, and revision of the abdominal
wound.
In other words, the presented case emphasizes
the importance of adaptability and agility in surgical decision-making when faced with unknown
and unexpected intraoperative ndings. The ability to swiftly adjust the management plan in
response to surprises encountered during the surgical procedure is crucial in ensuring the best
possible outcome for the patient. The multidisciplinary collaboration and meticulous approach to
addressing each unforeseen challenge underscore
the complexity inherent in managing acute hernia
complications in patients with signicant comorbidities. This case serves as a poignant example
of the intricate and dynamic nature of surgical
11 Surgical Decision-Making in Complex Clinical Scenarios in Abdominal Surgery: A Case-Based…
129
decision-making in the face of unexpected clinical scenarios, highlighting the critical importance
of remaining exible, proactive, and thorough in
the pursuit of optimal patient care.
When confronted with the challenging scenario of a large bowel being incarcerated in the
scrotum, we rmly believe that an emergent
exploratory laparotomy is the most prudent
approach to ensure optimal patient outcomes. In
our case we had to perform both laparotomy and
groin incision to facilitate and make possible
return of intact sigmoid colon. By opting for a
laparotomy, surgeons can safely and effectively
reduce the colon intact, with meticulous attention
to detail to conrm the absence of ischemic
changes and to alleviate any potential vascular
compromise. This approach allows for a comprehensive assessment of the incarcerated bowel
segment, facilitating timely intervention and
minimizing the risk of complications associated
with bowel compromise.
The laparotomy provides a controlled and
well-visualized environment for surgeons to
meticulously address the unique challenges
posed by a large bowel herniating into the scrotum. By carefully maneuvering and reducing the
colon back into the abdominal cavity, surgeons
can assess the viability of the bowel, identify any
signs of ischemia or necrosis, and intervene
promptly to restore optimal blood supply and
prevent further damage. The laparotomy
approach not only ensures the safe reduction of
the herniated bowel but also enables thorough
exploration of the entire abdominal cavity to
address any underlying pathology or associated
complications, promoting a comprehensive and
denitive resolution of the complex surgical
dilemma.
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Surgical Decision-Making
inDamage Control Surgery:
ASystem-Based Approach
RifatLati andRubenPeralta
12
Introduction
Damage control concepts and techniques have
been part of clinical armamentarium in trauma
and emergency surgery for decades. In recent
years, the damage control concept has expanded
to other surgical disciplines: emergency neurosurgery, orthopedics, thoracic, vascular, plastic,
and other surgical elds. Damage control surgery
(DCS) is characterized by abbreviated surgical
procedure and termination of the surgical intervention once the bleeding and contamination
have been controlled followed by continuous
resuscitation and denitive management, once
the patient’s physiology improves, or when other
injuries take priority. It is a staged approach to
take in consideration the physiological reserve of
the patient, and it is designed to avoid or treat the
lethal triad of hypothermia, acidosis, and coagulopathy. In addition, most recently, the so-called
lethal diamond have been described and include
R. Lati (*)
Department of Surgery, The University of Arizona,
Tucson, AZ, USA
Tucson Medical Center, Department of Surgery,
Tucson, AZ, USA
e-mail: Lati@surgery.arizona.edu
R. Peralta
Department of Surgery, Trauma Surgery Section,
Hamad General Hospital, Doha, Qatar
Universidad Nacional Pedro Henriquez Urena,
Santo Domingo, Dominican Republic
trauma induced hypocalcemia along with hypothermia, acidosis, and coagulopathy, as an important post-severe trauma syndrome [1, 2].
By addressing critical issues rst in a staged
approach, DCS can improve outcomes and
increase the likelihood of successful long-term
recovery for patients with life-threatening
injuries.
The decision-making process in DCS is complex and, however, requires solid knowledge of
physiology of the patient as well the associated
injuries or comorbid disease. In recent years DCS
is being augmented with other procedures such
as embolization and temporary mobilization for
severe bone fractures, such as pelvis and long
bones, and nally, DCS in the abdomen is being
subsequently treated with direct peritoneal resuscitation [3–5].
Traditionally, the common surgical practice
included the completion of the operation without
many regards of the physiological condition of
the patient. This concept, however, has changed
dramatically in recent decades. Pioneered by
trauma surgeons, where DCS was rst reported,
now it has expanded to many more clinical elds
and surgical disciplines. Therefore, multiple
strategies were developed to avoid this dilemma.
While the damage control surgery (DCS) has
become popular in the last few decades, this is
not a new concept. Historically the management
of devastating abdominal injuries has been documented by the work of others, but the most wellknown surgeon is Dr. Pringle, who described the
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R. Lati (ed.), Surgical Decision-Making, https://doi.org/10.1007/978-3-031-67391-7_12
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