Repeat Exploratory Laparotomy for Encapsulating Peritoneal Sclerosis

CHAPTER 1

My name is Josh Ng-Kamstra. I'm a Trauma and Acute Care Surgeon at Massachusetts General Hospital. So the case we're gonna be doing today is a case of encapsulating peritoneal sclerosis. So this is the kind of case that's kind of a nightmare for acute care surgeons. It's a disease that occurs primarily in patients who have had peritoneal dialysis. It seems that the longer that they've had peritoneal dialysis, the higher the chances of encountering this condition, although fortunately it does remain quite rare. The issue with this diagnosis is that it carries a fairly high mortality rate, and it's very difficult to treat. What happens with encapsulating sclerosing peritonitis or encapsulating peritoneal sclerosis, different names for it, is that due to an inflammatory process, a very thick rind develops over the surface of the small bowel, you know, causing the bowel to stick together, causing bowel obstructions, and it's difficult to treat medically, and in advanced cases that cause bowel obstruction surgery is really the only definitive modality of care. There are medical therapies that can be used to treat this in the long run, things like glucocorticoids, steroids, some of the immunomodulatory agents, things like azathioprine, the mTOR inhibitors, sirolimus everolimus, but at the end of the day, for cases like this, surgery is required in order to save the patient's life. One other medical therapy that I should mention is tamoxifen, which seems to help lessen the degree of fibrosis as well. So for a case like this, the general steps of the operation would be to review the CT scan closely to find out exactly where you think the area of obstruction is with respect to the site in the small bowel or large bowel as the case may be. Sometimes it's a bit difficult to tell exactly where the source of the obstruction is, in which case it's helpful to review with your radiologist, but having that roadmap in approaching the case will really help anatomically to sort of guide the place in the abdomen where you wanna focus most of your efforts. So after you've reviewed the imaging, you need to consent the patient for the case. Consenting for a case like this is involved in the sense that it is quite a high-risk procedure. Because of the degree of fibrosis and adhesions that have formed, there's a high chance of having tears in the bowel - so either full-thickness tears or partial-thickness tears, and those can result in, you know, missed enterotomies, intricate fistulae, complicated intra-abdominal infections. And so it's not just as straightforward as entering the abdomen, finding the obstruction, and dealing with the problem. The patient really needs to understand that they're at high risk of complications from a surgery like this. So once you've consented the patient, you bring them to the operating room, you perform your usual operative timeout, you start with - a laparoscopy can be performed, but in cases like this where the degree of fibrosis is extreme, the likelihood of a requiring a laparotomy to deal with the problem is quite high, even for folks with advanced minimally-invasive skills. So after you've completed your laparotomy, you want to explore the abdomen, focusing your attention on the area where you believe the obstruction to be. The biggest thing that you want to focus on is getting the rind or getting the cocoon or capsule off of the bowel, and then lysing the adhesions between the loops of bowel. Once you're convinced that you've dealt with the obstruction, you want to run the small bowel to make sure that you don't have any enterotomies, missed enterotomies. If you find any, you deal with them. Then you'd want to make sure you have good hemostasis before closing the fascia and closing the wound. This is a patient with multiple comorbidities. He has end-stage renal disease. He was previously on peritoneal dialysis. He's now dependent on regular hemodialysis. He also has myasthenia gravis, which complicates his anesthetic care. He was admitted to an outside hospital, and the surgeon actually did a good job in bringing him to the operating room to deal with the problem, but because of the degree of fibrosis and sclerosis, he felt that he couldn't safely proceed, and therefore the patient was transferred to Mass General for another set of eyes to try to approach the problem. And that's what we're gonna be dealing with today. So for a patient with this condition, in terms of their postoperative care, they'd need a nasogastric tube for ongoing enteric decompression. The chance of them having a prolonged ileus or paralytic ileus after a surgery like this is quite high, so you have to be prepared to deal with their fluid needs, their nutritional needs, et cetera, as you await resolution of bowel function, despite the fact that you've already dealt with the mechanical obstruction.

CHAPTER 2

All right, so this patient was at an outside hospital. Can I get a DeBakey? With a bowel obstruction, and he was taken to the operating room, was found to have a cocooned abdomen. They were unable to make progress at addressing his bowel obstruction, so he was closed up. We transferred him over here just for a second surgical opinion so we could take a look ourselves here. So they've already done a lot of the hard work of the laparotomy. They cleared any adhesions to the anterior abdominal wall, so we'll be addressing the peritoneal cocoon if we can. And if we can't, then we'll be approaching it as a palliative procedure doing a palliative G-tube. An alternative would be an internal bypass as well. Can I get a snap? I guess I could help you out here. Okay. I'll let it back to you. Get a couple laps up. Yeah, we got 'em. DeBakey and scissors. Metz. Okay. Okay. Okay, okay. Okay, okay. Okay. Okay, can I get a snap? See, where's the knot here, huh? Yeah, there's one there. Yeah, here. Actually let's start from here. Here. Here. Here. Yeah, there you go. Some suture bites here. Yeah. Can you cut this too? Here. More of it there. One of the reasons why we're going back quite early, so his last surgery was two, three days ago, is because if we wait any longer then he'll start to have additional thick adhesions on top of the sclerosing encapsulating peritonitis that he has, so I'm gonna make our lives as easy as possible and our chance of success as high as possible, so we're taking him back early. The biggest pitfall that we want to avoid in this surgery is enterotomies, particularly missed enterotomies. We're gonna be really careful with our bowel handling. Need some saline. Okay. Saline. Suction. Yeah, yeah. Yeah, yeah. Yeah, okay. Okay. The trauma. Thank you. Okay. Let's get all of this clot out of here if we can. Let's irrigate this, we'll just like try to clarify the tissues as much as we can. And the main point of obstruction is down here on the right side. I'll take an abdominal wall retractor as well. Can I get the Bovie? Can we get Metz? I'll take a Bonney as well. 21900. Okay. Actually just get the Kocher on this here. Yeah. And it's Secor, S-E-C-O-R. Yeah. Can I get a blade, I guess a 15 blade? Yep. You want a 15? Yep. Thank you. So the tricky thing with these cases is it's finding the tissue planes. Yeah, that's not gonna be bowel there, so... I'll take another Kocher please. I think that's the preperitoneal stuff there that you're holding up there. And we know from the CT scan that her biggest problem is on the right side of her abdomen. So that's my priority right now in terms of the dissection, is freeing up the right abdominal wall. Yeah, it's hard to tell exactly what this is here 'cause this could be posterior sheath here as well, you know what I mean? But that's just fatty stuff there and the muscle's above it. So it's less likely. Can you get Metz? That's where - if you want to suction, underneath us. Something is bleeding over here. It's just a raw circus over here. Let's pay some attention to the bleeding down here first before we do anything else. Yeah, something bleeding in here. Can I get a DeBakey? And let's just see, so this is preperitoneal stuff here. So I think it's this right here. Yeah. I see it. Yeah. Can you get just a clip actually. Put a clip under this here. So I'm gonna have it retract here on the Richardson. Yeah, let's put a clip on both sides of this. So just go top and bottom. So, go above that way. Another clip please. Yeah. Yeah. Okay. We'll take that abdominal wall retractor back. There's a bunch of old blood and clot down here on this side as well. Yeah, let's go back to where we were working. Okay. The cautery. I'm just trying to get around to free the lateral abdominal wall here. Okay. So I'm just taking a really good look at all of this. Just making sure there's no bowel in any of the stuff that I'm using cautery near. You got Metz? DeBakey? I'm okay for now just with these. So I'm just strategically trying to get around this really stuck spot right here, 'cause I know that based on the CT scan, the obstruction is really in this stuff here. Yep. This is old clot from the last surgery still. Okay. We get some more irrigation. So I think that this is still our best approach to get around. Question is, do we have some of the abdominal wall down or is this part of the encapsulation? And I think it may be part of the encapsulation. Some of these are fairly easy to manage adhesions. We'll get Metz. It's coming there. We'll work on some of this anterior stuff here too. Okay, I'll get the knife again. Whenever I'm in doubt, I'm just treating up toward the abdominal wall. I'm controlling what may be the bowel down with my fingers so that I know that the stuff I'm dealing with here is not immediately bowel. Could be bowel underlying it, but... Let's regrab here with more tension. Yeah. Okay. This could be like the... Posterior? Yeah. Posterior sheath. Yeah, I'm actually okay with that 'cause we're gonna get closer to the back here so that we can kind of come across and just drop it all down so we can see what we're dealing with. Do you know what I mean? Yeah. There's no way this is coming off from what's underneath it. You know what I mean? Yeah. Can I get a DeBakey please? Bovie. So we're getting close to freeing this bit from the anterior abdominal wall. Like I can touch my fingers together behind. And I think this is gonna be the crux of our operation. Is getting all this stuff down here. Okay, let me get the knife. Thank you. Can't really see what's behind. That's the only thing. There's this whole area that's like just plastered up to the anterior abdominal wall. Can I get the knife again? And I'll take a DeBakey again. Popped a vessel there. Yeah, I know. I'll take the knife again. Actually, I'll do the Metz for now. Give you more counter tension? Yeah, I would stay pretty high up there. I don't know. I don't know what's behind here. I'll take the knife. Okay, and so this by feel over here is not bowel. Or sponge? Yeah. See this is the sclerosing peritonitis stuff. I'll take the knife. It'll take a Bonney. Can I get the Metz? Yeah, I dunno. And be careful with the Bonney's there just 'cause I don't know what's behind this. I think it's okay. Look, we're making progress. We actually are. Yeah, actually just drop that 'cause I think that there's a nice little layer right here. Yeah. So my finger is like fully under this now and there is no bowel in any of this. Yeah. There's bowel underneath that stuff. Is it a little rent or what do you think? Yeah. Hmm? No, we're okay. Yeah, I think it's just a rent in the sclerosing peritonitis stuff. Okay. I just need to get this last little bit down. Okay. Okay. Okay. Okay. Pretty much off the abdominal wall there. Do you wanna set up the Bookie? Yeah, let's stick it on your side there. That's it? Perfect. Take the Bookie post. Okay. Yeah, a little higher, I think. I think that's good. Yeah. Then can I get some laps divided in thirds? Here, I'm just gonna back this up just a little bit. Yeah, I think a deeper one. Just a little bit to do some counter traction there. Yeah. And then we'll get another one over here and then we'll do another one up top on your side like this. Okay. And then just do another one just up here. If you can just move it over just that way a little bit. Just right there. Yeah, I'll take a... I'll take a DeBakey. Yeah.

CHAPTER 3

So it's all of this stuff here. So I want to take it all the way down to here. So just as long as we're happy that there's no bowel in this stuff here, which doesn't seem to be. Yeah. Yeah. Yeah, take that here. Bovie. Yeah. Okay. It's a very manual operation. Okay. Okay. Yeah. Thank you. And so, if we can get around the capsule then we'll be golden. I think this is the capsule here. Yeah. Yeah. See how it just really just encapsulates everything? Okay. Okay. Okay. Okay. I'd like to remove as much of the capsule as I can but... That's the appendix, yeah? Yeah. See that? The appendix. Yeah. Okay. And that's just omental fat that's getting sucked up into, so you see how inflammatory it is? This stuff here, you get really all that creeping fat. It's like creeping stuff that's from the... We got a very good plane when you... Yeah. Okay. We may need like the long cautery tip. Okay. Okay. So now we're actually starting to see the bowel and the intestines. Okay. Can we open the LigaSure? I think this stuff we should lig 'cause otherwise it's just gonna be super bleedy. So we just have to be careful here 'cause like this is where the ureter might get sucked in, so we can quite clearly see through that. So my goal right now is just to clear up the right lower quadrant. 'cause that's where the most of her obstructive problem is. Lemme see below my finger there. Yeah. Okay, let's put that there. Yeah. So all of this stuff here is the capsule that defines sclerosing peritonitis. So the goals are really to get the capsule off resect as much of it as you can. We should probably do an appendectomy while we're at it too, but we will pay attention to that in a second 'cause the appendix is gonna be super inflamed with all of this. Okay. Yeah. So just lig all this off here. LigaSure. Yeah, you can send that for - we'll send you more of it. This is right abdominal encapsulated peritonitis. Okay. Just take all this stuff off too. Okay. Then, sneak a little bit off, yeah. Nice. That's more of the same stuff? Okay, so now let's see. Can we free the small bowel from this? No. That's where we might have to come under this part of the capsule here, which is really quite thick and terrible. Okay. Let's Bovie there. Yeah. Or just, yeah, lig it. Yeah. Yeah, that works too. Yeah, sure. Okay. Okay. Bowel's hanging on just underneath it. I think we're good. Okay. Okay. Just lig this here. Okay. Okay. Just trying to find an easy point into this stuff here. So I can get under this like hard piece here. This, yeah. Yeah. Because there is a bowel that's like living like right underneath here, so I don't wanna, you know. Yeah. What about from up here? If we start taking this stuff down. Let us... Yeah. Just come over my finger with a cautery. Bovie. Yeah. I see that plane there. Yeah. Thanks. And I think we can lig this stuff off here. Sure. Okay. Let me do it through this way. Okay. Okay. Bovie. Okay, just Bovie that actually. Okay. We can Bovie that. Yeah, just use Metz and drop that down there. Metz. Nice. Yeah. Yeah. I need the lig. I'm just gonna take some of this stuff off. I know it's like omentum here, but it's tough to tell if it's omentum or like membrane. More membrane. More of the encapsulating... Yeah. This stuff here can come - yep. Yeah. You can take that with Bovie on my finger. Do you guys mind having a long Bovie tip? Thank you. Suction. Oh, did I just make a serosal tear there? I think I did. I think that's a serosal tear. Is that a serosal tear or is that just the... Oh, the... I think it's this serosal tear. Is it? It's hard to say, right? Yeah. It's bulging out more than I'd expect from a serosal tear, though. Yeah. Yeah. Let's try to expose it more first. Okay. So take this here. Yep. Okay. Yeah, I think this is the obstruction here. Yeah. Yeah. Just right in there. Yeah. I don't know, I'm like really uncertain. I don't know whether, I think there's like the membrane of stuff still on this or is that an actual serosal tear? It's hard to say. It could be both. You know what I mean? Yeah. Almost looks when you push like that, the fact that it goes down this way seems like a membrane. Yeah, I agree. 'Cause also I wouldn't expect it to bulge that much. Yeah. Yeah. Yeah. Okay, let's come back to that. Okay.

CHAPTER 4

So I think what we wanna do is we wanna manage this stuff here. So let's just focus our attention and effort on just dissecting this out. I'll get a DeBakey as well. Okay. And then let's get the Metz. Do you wanna just Metz this? Yeah. Tough to see what's going on there, yeah? Yeah. Yeah. It almost looks like serosa to me. Yeah, just ignore that little bit of bleeding for a second. We could get this band here, it's just unclear to me. There we go. Gotta figure out what's going on here with these... I think it's... And then there's that thing that's underneath there, yeah. I think there's nothing here. No. Just Bovie on this, or..? No. I think even if I'm going like this, I think you might be... Yeah. Here. Can I take the knife for a second? I see, this is nothing here. Yeah, that's nothing there. Yeah. Yeah. Its gonna... Until this. Drop this down a little bit there. Right back to you. Yeah. Can I get a Kocher? Anything you can do with this corner there? Yeah, I think that can go. That was just right there. Hey, yeah. So if we can get this valve down a little bit. Yeah. Yeah. Is there another approach to this though? Do you know what I mean? If we come through another side or... We can take this down here, let's do that. Here. Okay. I'll take the Bovie. Is there like another layer here before we get down to the bowel? Okay. Just get right onto it here. Okay. Bovie. Just open it up with Bovie and then, yeah. Yeah. Liggy. Okay. Metz. Yeah, just Bovie it, yeah. Okay. I think you can Bovie this just on my finger there. Yeah. Nice. I'm gonna take it right up here with the Bovie. Can I get Metz? Here, we'll try to get down too. Yeah. It's all seeming to come down now. Hey? Kind of? It's just really stuck up there. Hey. Yeah a few little bands we might be able take here. Actually, I'm not sure. I think this is where the obstruction is though. This is what I would guess. Well, this is that on the CT scan we saw, I kind of saw this here. Yeah. Yeah. This is like... It's like cell layers here, hey? I feel like I'm back in histology class in med school cutting slides. Right? Okay. Nice, nice, nice. Okay, so now is there any bowel involved in this stuff here? I don't think so. Want me to see if I can push 'em down more here, looks pretty nice? I feel like there can't be anything above me here, but... Yeah, I agree. Here. Back to you there. Yeah. Take a feel. Yeah. So you mean just open it up, yeah. Yeah. I think we can. Yep. Let's be bold. Yes. You can go to there. Just a rock. Hey? Here, gimme a second. Want me to go... Okay, there you go. I did already the last few days. That's good. You want put my finger in there? No, we're good. Go for it. Okay. And go just down to there. Might see a vessel or something in there. Yeah. Okay. Can I get the knife again? Thank you. DeBakey. Thank you guys. I don't dunno if that's the right plane. It feels like it's kind of getting into the... Into the fibers. Yeah. Okay. I wonder if we could peel it off here and see if we can drop that down. Yeah. Yeah. If you lift that up, let's see if we can get underneath it. It's tough. It's like, I don't know how much that's gonna give us. Okay. Can I get the Bovie? I'm just gonna take this guy off here. More of the same stuff. I feel like we have to come across here at some point. Can I get the Kocher again? Okay. Yeah. Can you go that way at all? Not really, hey? Can you just put your fingers just like this for a second? Because I think like there's a band right here that's holding us back. Can I get the knife? See it's the - this is a piece of the disclosing peritonitis stuff. Okay. Getting somewhere there. But I still think in order to really free everything we need to somehow come through here. Like under here. Do you know what I mean? Just so this, this all reflects this way. Yeah. Yeah. Can I get the knife? That's what we're gonna do. Gonna take this here. Kocher? DeBakey? Can you see better from your side there? Here, I'll take that Kocher. Was there a bind? Oh, sorry DeBakey? Sorry, I misspoke. Thank you. Pulling up for a smooth, so I can do a little bit. That was a little blow for freedom. We're gonna need some Arista powder for the end of the case Bovie this here. Yeah. This band, which is just like fused to this loop of bowel Knife down on your tray. I think this is all part of the encapsulation, you know? Yeah. Yeah. The question is, can we divide this guy here without dividing the loop below it? That would be very tricky. Can we get from all the way below here? If we come from over here. Bovie. Okay. I think this is safe right here. I think you can Metz some of this here. Metz. Okay. Just once cell layer that way, yeah. All right. So this is mostly up now. We are making progress. Let's do some Metz in here. Here, let's just leave that for a second. No worries. Keep working in here. I think this corner, like this edge here is gonna be... See there's like a whole line there. Yeah. Just above it. So that's coming free there. This bowel is dilated over here. It's stuck to that - this on top of it here, which can come off. It's a little thicker there. Nice. Okay. Okay. Okay. That looks like possibly the pathology. Yeah. Maybe kind of, sort of. Yeah. Okay. Well I think the actual obstruction is still deeper there, but we're getting to it. Okay. You can Bovie that. Bovie. Okay. So this is all coming up here. There is definitely a kink here. Bovie. Let's get that there. I think that's it. We're getting to the obstruction though. I agree. I just wanna see if this band here... Just do this one first. Yeah, it's bothering me. He's pretty oozy. So what was his starting hemoglobin? It was - let me look again. 9. Nine? Okay. Yeah, I wouldn't be surprised if between all the ooze and everything we lose four or 500 during the case. So just for your context. Yeah. I think we're getting close to the obstruction. Need to be a bit careful down here with like vascular stuff. Okay. Nice. All right, I think we're gonna have to come this way. I think... We gotta define that? Yeah. Here actually. Yeah. You see this stuff here? I think that's where the - part of the problem is. Approach it from this side here. Yeah. Yeah. Nice. It's coming. It's coming. Okay. Okay. I think it's actually here. Yeah. People always make fun of me for wearing loops in these cases, but... No, I think it's smart to always wear loops, too, actually. Yeah. The biggest reason why I do it is because my loops have a really great headlight built in. Yeah. I don't have it on right now just 'cause like, I like to kind of transition between the loops and not loops and so if your headlight is like looking one direction, you know what I mean? Understood. Yeah. And it's like, yeah. Okay. And then I think this is the problem or this is part of the problem. I see this band right here. I'll take the Metz again. No, maybe just pick up that leaf there. Okay. Okay. I think part of the problem extends down this way too. Yeah. Yeah, if we could somehow - 'cause this is one loop of bowel that's attached to this, so we should be able to divide this one up. Yeah. Yeah. There's a little plane developing here. This is I think what we were getting at before. Yeah, yeah. If you hold up that way, I have a good angle here to take Metz. Metz. You know, I think you even want to take this, take it this way. Yeah. Take it off that side? Yeah. Yeah. In which case you might have a good angle. Yeah, I think you got not a bad one there too. Just step a little higher there. Good. Okay. And then let's go back to how we had it before. So I think your hand was in here. Was it? Get rid of some of this blood here. What was I lifting up on? I was lifting up on like this here. So here, can I give this to you? Yep. I think this is part of the issue here. See how it's like, it's really twisted right here? Yeah. Can I get a right angle dissector? Then just Bovie across that there. Nice. Okay. Okay. Bovie back. That was a nice blow. Yeah. One more band here. Yeah. We got that loop up now, right? Yeah. That loop that was stuck down. That loop is up. Yeah. Mostly. Here. Yeah. If you lift that loop about up. Yeah. Yeah. Like that. Then you can see better. All right. So now we have this loop that's somewhat freed and then this is still stuck right here. Can you take any of this down you think? I think so. It's pretty stuck there still, hey? Let's try to come down here. Yeah. It's just a little window here. Okay. Okay. Okay. How are we doing here? This is still pretty stuck over here. So we freed most of this. There's still this stuff stuck to here. I think we could separate these bands here from each other. Yeah. Yeah. Yeah. Okay, so then this still needs to come off this here. So what do we need to do? So we need to get this off of this. So everything off of this side thing here. And then where does this loop go? It already seems pretty dilated. Yeah. So I don't think- more proximal to the pathology... Yeah, no, I think you're right. Yeah. Just try to open a bit of this up here just because like, just like over here, you know what I mean? With this stuff is. Yeah. Yeah. Is that just the same loop, just like kind of folded maybe? No, I think, yeah, maybe. I don't know. Is it? Is it the same look as this here? Yeah. I think so. Or is there like a plane right there? I think there's a plane. Did you hear me? Yeah. Not that we absolutely have to get that down, but okay. Let's try doing a bit right here. Do you know what I mean? I think there's like this loop and then there's this loop maybe. I don't know. DeBakey. Let me get the DeBakey as well. I'm gonna try to get under this, ideally. You think it's under here? Yeah, I think you're right. Okay. This loop. So this all of this stuff that's still a little bit dilated. This loop had been stuck down to here, right? Or where was that loop stuck down? It was stuck down in here. So then this stuff is still all dilated. And then let's separate this off here. You can. So Sula, it's all about seeing planes that you're probably like, I don't even know how they know what they're cutting. There have been moments. Yeah. Yeah. So, the tissues give you these really subtle cues though. Like you'll see a little bit of just areolar tissue, like a little bit of air and then you're like, oh that's where the plane is. And then there's techniques like putting enough tension, counter tension and then sometimes you really don't see a plane. And then that's a good moment to think about using a knife and just sharply dissecting on the side that you know is safe. And sometimes you can see the plane very clearly but the bowel is still very stuck to the plane. And so that's also a good moment to use the knife rather than the Metz or the Bovie. It's coming. Yeah. Yeah. That's Bovie-able, just right like there. Oh yeah, there's some nice tissues there for you to get with the Metz all along here. You can go straight through that stuff. Nice. Okay. You can take this stuff down off here too. Here, right here. Just gonna take this stuff down here. Okay. Okay. We have to remember to look back at the colon there too. And imbricate that. I think it might be a serosal tear, so... Nice. This is all coming off here. Okay, so just take this whole chunk of stuff off. Hey, we're almost down to that spot where there's that weird band that goes across there, so... Nice. Maybe we can get this stuff all off now. I don't think there's any bowel in here. Yeah, can come straight. There's bowel there. So, maybe... Yeah, like just here. Nice. Okay. I'm still having some bleeding down here. Can we get, yeah, suck that up. And then we'll... I think we're maybe, we've either gotten to the obstruction or we're very close to the obstruction. I just wanna kind of get rid of some of this. I'll get the Metz here. I'm gonna cut some of this off here. Yeah, I'm just gonna stay a little bit high here. Okay. More of the same stuff. I'm not sure if I'm going through the right thing, or just a random... Yeah, I mean I think it is just part of all the capsule here. Yeah. Yeah. It's not mesentery for sure. Right? So like, yeah. Okay. Is this another band here? Yeah, I think it's a band. Yeah. You might be getting to mesentery there, so... Yeah, yeah. Yeah. I think just come across this with like, yeah just, just get your Bovie and just come across it on my finger because then that will like definitively deal with this band here, you know? Okay, there you go. And then band it up. Ooh, no, this is kind of coming here. There should be a plane between these two. Yep. And I think there is right there. Yeah. Yeah. Trying to make sure of something? I think that's all okay there. Yeah. Yeah. I think you can just Bovie across that. Nice. Okay. So let's see where we're at now. So, have we found the TI yet? I don't think so. Do we need to find the TI? I'm not so sure. Okay. So we have the cecum here. Yeah. So this is probably TI coming in here. No, the TI should be decompressed. Right? And this is like, okay. And this could be coming in here. Do you know what I mean? Like this could be TI coming under this stuff and going in there. Okay. Okay. Okay. So this is stuck to this, but not kinked right? Here, just... Yeah. Yeah. Yeah. Yeah, okay. So... The question is, do we need to get it off all of this stuff here? 'cause this is like kind of the riskiest area where it's sort of stuck all together here. Can I get the lig? Can I get a fresh lap pad? Thank you. Sure. Just put it, you can put it all together. Actually that's just garbage. Just, yeah. Okay. All right. So... We need to take this all off here, I think, so we said this might be TI diving back here. It's a bit hard to say. Okay. Can I get a right angle? And that's just nothing, right? Yeah, that's just nothing. Yeah. Okay. Okay. Yep. So we separated that off the top of this here. Bovie this here. Bovie this here. Yeah. Okay, so then where does this go? So, can I have a DeBakey, just pick that up there. Okay. So, this band here? Okay. Okay. Okay. Let's pick that up there. Okay. Another DeBakey. I like, there we go. Bovie. Thank you. Stay on the top side there. Yeah. Okay. Okay. Okay. Let's see. So we got this piece that we freed up to here. It's still stuck to this midline stuff here. And then we freed this here. Let's free these two loops. I think it's right in the middle there. Yeah. A little bit to the bottom here. Yeah. I would aim a little bit this way. Yeah. Okay. Okay. Okay. Okay. That's pretty free there. Yeah, that's honestly free enough. We don't wanna get digging into the mesentery too much. Just Bovie this across here. Okay. Okay. I think this may have been the spot that was obstructed. Yeah. You see where it's like, yeah. It looks undilated, dilated. Yeah. Yeah. Okay. Okay. So, yeah, 'cause this is... Undilated, this is clearly dilated, and there is non. Yep. So we're clearly beyond it. Yeah. So let's just point to it for the camera here, so... This goes distally here, right? Where? Here. Yeah. Think it was this band here. Right here. Yeah. So this is probably the spot that was obstructed, that was stuck way down there. So, you know. And so now we haven't gotten rid of all of the adhesions, but I'm pretty confident that we've dealt with the obstruction. And I feel the peristalsis. Yeah. Yeah. And with these kinds of cases, you have to know when to stop. And so far we haven't created any full-thickness enterotomies that we know about. And we've freed up the bowel pretty significantly here. This is certainly dilated bowel, so that was proximal to the obstruction. And all of this is dilated as well. Okay. All right. So, I'm not what I would call happy, but I am what I would call satisfied. How do you feel? I concur. Yeah, okay. Okay. Now... I'm not stoked. Yeah.

CHAPTER 5

Are we gonna deal with this appendix here? Yep. Yeah. So how do you wanna do it? Staple. Oh. Schnidt here. Yeah. Or we could just take the liggy and go to the mesentery. Yeah. Yeah. Can we get a 2-0 silk suture? We're gonna purse-string it and dunk the base. Sounds good. Love it. Because we don't need a stapler. Do you want me to take the...? Yeah, yeah, yeah. Yeah. And I think like in this case, we kind of have to take the appendix 'cause the appendix is so beat up and like nobody is ever coming back into this abdomen. Here, just make a little, yeah. A little bit back. A little bit back. There you go. Yeah. Yeah. Nice. Okay. Okay. So then we're gonna make a purse-string around here with your... Okay. Don't tie that down just yet. So, can we get a, just a Vicryl tie? Yeah. 2-0 okay? Yeah. Pass or free? Just on a pass. Yeah. Just tie it above it? Yep. And then we're just gonna dunk this stump after. Okay. Okay. Yeah. Suture scis again, yeah. Yeah. Here. Okay. Appendix. Nice. And then, yeah. And then get DeBakeys. Then you can cut the suture there. Yep. Pretty much right on the knot. Yeah. Thank you. Yep. Now we're gonna dunk this stump here. Another DeBakey? If we can dunk 'em in inside and then... And then we'll tie it? And then you'll tie it. Okay. Yeah. Yeah, yeah. I might not dunk super nicely, here, one second. That's just going for permanent, correct? Yeah. We have to loosen up on this just a little bit here. Where's the edges of that? DeBakey? Yeah. These are a little longer. I dunno where the other ones are. No, I took it out. It's not dunking right. Yeah, just tie that down and then we'll purse-string it again and dunk that. Yeah. Okay. Yeah. Yeah. Yeah. It's a little bit - it's fine. Because I don't think it's gonna dunk nicely, but we got two nice sutures on it, so we're fine. Okay. Okay. Alright.

CHAPTER 6

Okay, so let's make sure we don't have any bleeding back here. I just wanna open this up here 'cause I think this is the... It's a strange-looking serosal tear. The fact that you're dissecting it that easily makes me think it's just scar tissue. Yeah, I think it's just - I don't think it's actually a serosal tear. Yeah. I agree. Let's come a little bit more into my finger there. Yeah. Yeah. I think that's not actually a serosal tear. I agree. I really don't think it is. Yep. It was just the scar tissue looking weird. I see what you're mean, but... Yeah. Yeah. The bulgeof it makes it... Yeah. Unless we just made a bigger serosal tear, which I don't think we did. I think it was just the scar tissue that was on top of this. No merit in imbricating it empirically, right? No merit to indicating empirically? Well that's my question. It's like is this actually a serosal tear or not? I don't think it is because like that's clearly not colon wall. Yeah. Do you know what I mean? I agree. Yeah. Yeah. And it's like that's continuous with everything else. And that bulge, I agree. Yeah, and it's that bulge. Well actually now it's like, 'cause this is normal colon, this might be actually be a serosal tear anyway. Do you know what I mean? Yeah. Yeah. Let's just imbricate it. Yeah. Because I think there is a serosal tear because I think this is normal colon and this is serosal tear. I think this was like, yeah. Vicryls? Yeah. We'll just do it side to side because I don't think we're gonna be able to get it. You think we're gonna be able to...? No, I think we'll just do side to side. Yeah. Or will we narrow it too much? What do you think? It's hard for me to say. It's an unusual-looking serosal tear. Yeah. And the fact that you were able to dissect underneath it so easily and like it was just a scar tissue. Yeah. But the fact that there's like there's linear things on it now. Yeah. Let's just imbricate it. And I think we'll do it side to side. I don't think we'll narrow it too much because if we're gonna do it end to end, it's gonna be like way back there. Do you know what I mean? Yeah. Let's just do it. Okay. We'll start like on your side there. Let's get 3-0 Vicryls. I think we'll I imbricate it anyway. I wonder if this is normal serosal and then the tear is just this portion here. Yeah, I think it is. Like this. You see? Yeah. You see that? Not this far line but this one. Yeah, I think you're right. So this is the V of it. Yeah. Here you go. Yeah. A little trickier from this side. Yeah. Just watch your things on the... Trying to get some better exposure here. I just wanna see the edge better. Yeah. Yeah. Yeah. Roll it to there. Yeah. Yeah. Yeah. I think it's like here to here. Yeah. Like this stuff could also just be the, no, I think there is a little bit of a serosal tear. Is there a way to rotate a little bit more? Yeah. Yeah. I think that that stuff is just the sclerosing, like the capsule. Do you know what I mean? That's fine though. We know that this stuff is tough, so... Maybe split the difference and go like there. Needle back. I don't even another snap, I'll just drop them here. Yeah. You wanna start from this side and then tie as you go until you get to there. Yeah. This side is more convincing that there is actually a serosal tear. So I think it's all the way up to here. Yeah. Bring these edges here? Yeah, like, yeah. This to here. I think there's like this to this. Yeah. Do you see? 'Cause I think this is the tear that like comes up there. Yeah, I see that. Yeah. It's because of the bulging, the horizontal bands, and the fact that there's like nearby tissue that's more superior if that makes sense...? Yeah. Yeah. I think this here, right? Yeah. A little bit further back to the side. Yeah. There you go. Yeah. Needle back. Do you think the edge is way back here, yeah? Can I get a DeBakey? It might be way back here or that's the spot? So I think the edge is here. Yeah, and go there to there. Yeah. Needle back. I think your edge is like here to here. Yeah. This is definitely a serosal tear. It's like so obvious now. You know what I mean? I think now your like edge is like here. Like here. Yeah. With these closures, it's pretty obvious. I wouldn't have slept well tonight if we hadn't have closed this. Yeah, I think we went way further back than we need to. Well this one I think you can tie like, this one's not too crazy. I wonder if that's the edge of the serosal tear. I wonder if all this stuff I did here is not it at all. Yeah, I think this is the edge here. Yeah. I'm saying all this stuff here that's not further down. Yeah. I'll take one more. I think it's like seven. You know. Okay. What do you think? Tie this one or no? Yeah. Tie that one. That might be... I have not switched it in time. Okay. You cut out the rest? Lemme see. I think you might, I think you should just tie them. I think you're okay. Yeah, yeah, yeah. I think you can tie them. Like it's not narrowing it. Do you know what I mean? Yeah. Last one. Very nice repair. Yeah, yeah. Yeah, yeah. Looks better though. Yeah. I'm much happier with that. Yeah. That looks more normal. That's the repair of our serosal tear. Let's get rid of some of this blood in the meantime. So, that's the serosal tear. I'm happy with that. Okay. Can we get some irrigation? All right. So that's not bad there. Okay. So we've done our appendectomy. Down here - that's all fine. Can't really see the TI properly, but it may be coming in just underneath here. Can we do any more of this stuff safely? I'm inclined to leave it 'cause this stuff was part of the decompressed bowel here. Right there still? Hmm. It was this area. Yeah. This, this was all decompressed and now it's kind of filling up. So, yeah. You wanna go taking some of these? Yeah, we can, yeah. Why not? Let's do it. Yeah. Metz. Okay. Okay. Okay. Okay. And then there's this stuff here. We don't need to necessarily get all of that. 'cause this is like, yeah. And this gets into the dilated bowel over there. Okay. And there may be a plane in there. I don't think it's worth it 'cause this is all, it's - this is all decompressed bowel. Yeah. Or this is, that's all - dilated bowel. Dilated. Yeah. Okay. All right. And let's, for the sake of posterity, let's just run this bowel that was, you know, close by. So, no injuries that we see here. Nothing here. Nothing here. Yeah, and this is so plastered to here that we can't get it off safely. Same here. This is just digging ourselves into a hole that we don't have to be in. And so this bowel... Just carefully running it along. With loops on, I might add. If we miss an enterotomy with this, it won't be for lack of trying to find it. Okay. Looks a little narrow here still, doesn't it? Yeah. I Wonder if there's any bands to free up. Nothing obvious, but... Not really. Okay. I think it's just irritated to be honest. Yeah, I mean that's where it was. Yeah. Yeah. Okay. Okay. Okay. Okay. Okay, and then this here, this is still stuck here, but we can't get that off easily, so we're not going to. And then this comes under here and I think it comes under to the colon there. Okay. So, I think we've dealt with the obstruction and I think further dissection would be hazardous. You agree? Yeah. Okay. I wanna make sure no band there. Yeah. Okay. Can we get the Arista powder? Yeah. Okay. Okay. Okay. I don't know whether this will make things more sticky, but yeah. Here, let's just try that out there. I would say probably about 300. Okay. Thanks. Okay. Okay. Okay. And let's look here. There's definitely something that's dripping back here. Is it coming from up higher though? Can I get a dry lap? Running down from the lateral wall somewhere. From like higher up on the lateral wall? I believe so. I've seen it run down from lateral to medial here. Okay. Okay. And maybe it's this stuff in here. Here. I'm just gonna get a bit of generous sprinkling of Arista back here. Okay. And then my Arista in here. Okay. And then anything bleeding up here? Let's take these guys... Worth taking a look more there or no? I don't think so. Okay. Where can we put more of this stuff here? Okay. Oh yeah. The ones we had in Toronto didn't have that extra little thing, so, all right.

CHAPTER 7

Can I get a Kocher? So now we have to figure out what we're closing to what. Another Kocher? And I don't think that there's any utility in going to the left side. No, I mean it was pretty clear where the transition was on the CT scan finding that corresponds. Yeah. And then just one more Kocher. Regular pack is okay? I think so. He's doing okay up top? Yeah, he's doing okay here. Here. You want me to just tie it or? Yeah, here, just go up that side. I think we're good. Do we get it? Yeah. I'm gonna take another bite back there just to make sure. Yeah. So Sula, when you're assisting with a lap closure, the way that I recommend to do it is you put your hand on top of the two Kochers here and you push down with your wrist and up with your fingers and then you pull up with this suture here. And that way you give them tons of room to work while keeping your hands out of the way. Because if you have your hand on the top, it's like then your hand just gets right in their way. I'm not happy with all this bleeding there. I'm worried that there's still bleeding there or not. Okay. Yeah, yeah. Where is the... Yeah, it's definitely like still going a bit. You can see it under there.

CHAPTER 8

So that was a challenging case for a variety of reasons. Number one, because it was a reoperative case. So we were exploring the abdomen again after several days after another surgeon had already been in the abdomen. One of the reasons why we decided to explore him again so early is that if we had waited a few more days, he would've developed in addition to his encapsulating peritoneal sclerosis, he would've developed postoperative adhesions from that as well. So we wanted to maximize our chance of success in dealing with the problem. So when we got into the operating room, we explored the previous abdominal incision, I had thought that there would be fewer adhesions to the anterior abdominal wall given his recent exploration. But there were still a number of adhesions, especially in the upper abdomen. And particularly right in the middle of the abdomen, there was an area that was densely adherent and I think it was the posterior sheath of the rectus that was really densely adherent to the bowel and really incorporated into that cocoon of scar tissue. So that took quite a while to deal with and to free the abdominal wall from the bowel. In this case, we knew from the CT scan that the obstruction was on the right side of the abdomen. So we really focused all of our tension on the right side. There were tons of adhesions on the left side as well that we simply left alone because we knew that that wasn't the side of the obstruction, at least radiographically. The adhesions on the right of the abdomen were indeed very dense. It took a lot of careful dissection involving, you know, selective electrocautery, dissection with Metzenbaum scissors, the occasional use of a 15 blade for really fine planes. And, so, you know, it went about as I would expect a case like this to go requiring several hours of dissection. We also discovered that in the course of our dissection, we'd created a serosal tear in the colon. It was a little bit difficult to tell whether it was indeed a serosal tear because, you know, there was that layer of scar tissue on top of the colon. So we didn't know whether it was just a defect in that scar tissue layer or whether it was an actual serosal tear. But once we made the decision that it was a serosal tear, it was fairly straightforward to repair as we did with interrupted Vicryl sutures. Otherwise, in the context of his renal disease, he was more oozy than most patients would be. You know, we used Arista powder to secure hemostasis at the end of the case. You know, I am quite confident that we were able to find the area that was obstructed. We did just as much dissection as I thought the patient needed. You don't wanna end up leaving the area of obstruction behind, but you don't also wanna get into additional dissection of small bowel that risks enteromoties, et cetera when you're focused on one area that you believe to be the problem. And then, you know, at the end of the case, we encountered a superior epigastric vessel in our closure. We had to reopen part of our closure to resecure hemostasis. But then after that I was fairly happy with the hemostasis and we'll see how the patient does postoperatively.