By Tedler D. Depaynos, MD
The patient was a 72 years old who underwent surgery due to Acute Appendicitis more than a year ago. Although he is a retired government employee, he went back to backyard farming because he got bored doing nothing. Months after surgery, he felt a bulge over his incisional wound which became bigger as months passed by. He could reduce the bulging by pushing it backwards and he knew that it was an intestine protruding out because he could appreciate the contraction sounds and movement. He learned that lying down would make the reduction easier and he started wearing abdominal binder which he bought in an athletic corner in a local super mart. Two weeks ago when he started coughing, the bulge appeared to be getting bigger so he was forced to seek consultation.
Obviously, the impression was Incisional Hernia which was confirmed by an abdominal Ultra Sound (UTZ).
The abdominal wall is made up mainly of the skin, subcutaneous tissue, fascia and the lining adjacent to the intestine called peritoneum. All of these layers are incised during surgery and then repaired individually in the closure of the abdominal wall after the procedure. Somehow the closure gave way especially the fascial layer providing an opening where the intestines could protrude. In this kind of hernia, the bulging intestines could easily be “reduced” because of the wide opening. There are some cases however where it becomes “irreducible”. In the other types of hernia like Inguinal Hernia where the opening is small, the blood vessels of the protruding intestines may be compressed or “strangulated” and because the intestines may become gangrenous, severe pain may be experienced by the patient. This is the most unfortunate hernia complication.
Initially, the consulted surgeon was doubtful if it was a case of Acute Appendecitis that the patient had. The incision was a right paramedian and quite long. Incisions in Acute Appendecitis are usually transverse, 3 to 4 inches at the right lower abdomen where the appendix is located. It may sometimes be slanting. In this patient probably other cases were entertained because the patient is already at his 7th decade. Appendixes at this time are usually atrophied already so that the probability that the patient was suffering from Acute Appendicitis was much less. A colonic problem like diverticulitis, obstruction etc. was probably entertained by the surgeon.
It could also be that an abscess formation was entertained so that a wide opening was needed to thoroughly clean the abdominal cavity. With abscess formation, infection likewise of the abdominal wall is sometimes inevitable, Experienced surgeons thoroughly wash the abdominal cavity and wall before closing. In some instances, the washing may even take more time than the procedure of removing the infected appendix. In this patient probably, the fascia got infected which lessened its strength and gave way to the formation of the hernia. Actually, infection is a common cause of Incisional Hernia.
The coughing of the patient was controlled and after being cleared by Internal Medicine MDs he underwent repair of the hernia where a mesh was applied on the fascia for the fibrous tissues to eventually grow and strengthen the abdominal wall.
It was an uneventful surgery and he was advised to relax working in his back yard farm and not to forget to wear his abdominal binder while healing is still taking place. And he has to remember that he is already on his 7th decade and if his skin has already wrinkled and weaken and so are the other tissues in his body.
PROFESSIONAL FRUSTRATION
The patient was a retired underground miner who returned from their province and joined his relatives once again because they were suddenly making good in their underground adventure digging for the elusive glittering yellow metal. He was beside a motorized mining trolley and as they were exiting the small tunnel opening, his long loose pants got caught in the wheel axle so that he was dragged and in trying to stop the trolley using his other leg it was caught beneath the wheels and he incurred a very painful open crushing injury. None of his co-workers could exactly describe how it happened because at that moment, he was alone guiding the heavy trolley.
The fracture of his right lower leg was obviously multiple involving the two bones because it was open. This was confirmed by a simple x-ray which also showed the extent of the damage and their displacement. An Orthopedic Surgeon was immediately called who did an emergency debridement even at the very unholy hour. The emergency debridement was mainly cleaning of the wound and removal of the necrotic tissues which would hopefully prevent infection. It would also ensure the blood supply of the affected extremities which may have been lacerated, compressed by hematoma or some fractured fragments or even by immediate wound swelling since the trauma was massive. After the procedure the pulse became stronger and there was no sensory deficit.
In wounds like this, a series of debridement is usually done because more necrotic tissues would be more evident as days pass by. Uninfected granulation tissues would also be obvious. The main objective is to prevent infection. Bone infection (osteomyelitis) is hard to control and the healing of infected fractured fragments is next to impossible. Placing of foreign bodies like “titanium plates” is inadvisable. This is routinely emphasized to patients but there are cases which are misunderstood usually by visiting relatives. Because of the impending bills that accompany the series of procedures, they thought perhaps, that the attending MDs are taking advantage of the patient despite the explanations.
In this patient, the relatives requested that he would be transferred to a government hospital because of the bills. The Orthopedic suggested that it would be better if he would be transferred to a government hospital he is connected with so that he could continue his work even on a charity basis. The close relatives were initially amenable but then a family close friend insisted otherwise. Being a professional, the Orthopedic did not argue but while conversing over a cup of coffee, he appeared a little frustrated. Whatever he felt, however, he took it as part and parcel of the profession. He just hoped that the patient would eventually be alright. He later learned that it was a prominent member of their local church that insisted that the patient would be transferred. **
