VM23 - Sorting out the Mess: Principles of Reoperative Surgery

Purpose/Background: This case presents a 37F with a history of crohn's disease with known enterocutaneous, enteroenteric, and enterovesical fistulas after multiple previous abdominal operations. We present an organized method to approach workup, surgery, and postoperative care in a complicated reoperative patient.

Methods/Interventions: The patient had preoperative visits with Wound Ostomy, Urology, and Plastic Surgery. She was optimized with TPN and wound care. Surgery was planned for at least one year after her most recent operation. She underwent cystoscopy with bilateral ureteral stent placement prior to exploratory laparotomy. We explain principles including operating from known to unknown, working toward the areas of worst disease, and having a thorough exit strategy. In this video we demonstrate techniques of thoughtful incisions, hydrodissection with injectable saline for careful lysis of adhesions, running to bowel in crohn's disease, and betadine injection to identify inadvertent injury to bowel. We also model our technique for handsewn end to end small bowel anastomosis.

Results/Outcomes: This patient had both a disruption in a previous staple line and a twisted ostomy causing internal herniation of her small bowel. She underwent repair of the enterocutaneous and enteroenteric fistulas, resection of anastomosis with hand sewn end to end anastomosis, bladder repair, re-siting of her end ileostomy, and complex abdominal wall closure. Finally, a loop jejunostomy was matured to allow for appropriate healing.

Conclusion/Discussion: Important principles of reoperative surgery include optimizing the patient, involving all anticipated subspeciality teams, "circling the enemy", operating from known to unknown, and having a thorough exit strategy if the surgery is not feasible. This includes being liberal in the decision to create a high jejunostomy requiring short term TPN use to allow for proper healing.