ICS SOA 2015

1. St Mark's Hospital
and Academic Institute
The Complex Surgical Abdomen in ICU: When do you
reopen?
Janindra Warusavitarne
Consultant Colorectal Surgeon, St Mark’s Hospital, London, UK.
State of Art Meeting Intensive Care Society 2015

2. St Mark's Hospital
and Academic Institute
intensivist
Surgeon
Radiologist or
anaesthetist

3. St Mark's Hospital
and Academic Institute
SURGICAL CASE

4. St Mark's Hospital
and Academic Institute
70 year farmer
• ITU to ITU transfer to intestinal failure unit in
01/10/09
• Requested by ITU Anaesthetic Consultant

5. St Mark's Hospital
and Academic Institute
Clinical history
• Hartmann’s for T4N1 rectal cancer June 08
followed by chemotherapy
• Reversal of Hartmann’s, ileostomy 17/08/09
• Re-laparotomy, high jejunostomy for mid
jejunal tear, mesh closure, VAC 19/08/09
• Re-laparotomy for jejunostomy retraction,
closure stoma 26/08/09
• Re-laparotomy and debridement, VAC
27/08/09

6. St Mark's Hospital
and Academic Institute
• Re-laparotomy for caecal perforation
02/09/09
• Re-laparotomy and fasciotomy for fat
necrosis 18/09/09
• Attempted to control fistula with Foley then
tried to repair it using Permacol
“I duly therefore closed the fistula primarily with
two interrupted vicryl sutures over a
Permacol overlay”

7. St Mark's Hospital
and Academic Institute
On arrival
• Septic, ventilated and on inotropes
• Tracheostomy
• Severe chest infection – E.Coli
• Bilateral pleural effusions
• Anuric
• GCS 10/15
• Laparostomy, with prolene mesh, stoma and
fistulas
• RIF collection, Candida in drain fluid

8. St Mark's Hospital
and Academic Institute
Early Surgical Interventions
• Removal prolene mesh 06/10/09
• Oversew of arterial bleeder eroded by
bowel contents 28/10/09
Transferred to IF ward 10/11/09
Total ITU stay of 83 days (both hospitals)
Discharged home 17/02/10

9. St Mark's Hospital
and Academic Institute
Relating psychology to decision making
• Poor communication with patient/family
– Fear of being criticised
• Personal feelings interfering in
appropriate decision making
- Need to fix the problem at all costs

10. St Mark's Hospital
and Academic Institute
Conceptual Treatment Goals
• Sort out the problem
• Try to repair anastomotic leaks
• Close the abdominal wall
• Starve the patient till any fistulas have healed

11. St Mark's Hospital
and Academic Institute
Realistic Treatment Goals
• Do not make the problem worse
• Divert sepsis/leak
– Radiological or surgical drains
• Open abdomen
• Enteral nutrition where possible

12. St Mark's Hospital
and Academic Institute

13. St Mark's Hospital
and Academic Institute
Mortality associated with septic shock
• Emergency presentation with septic shock
– Mortality about 34%
• Septic Shock after elective surgery
– Mortality about 42%
• Re-operated patient
– Mortality 40-72%

14. St Mark's Hospital
and Academic Institute
What are potential reasons for re-operation
• Sepsis
• Multi-organ failure
• Ischaemia
• Abdominal compartment syndrome

15. St Mark's Hospital
and Academic Institute
Sepsis/ multi-organ failure
• Source control – drain sepsis
– Best done at initial operation
– Drainage of any collections
– Possible role for laparoscopy
– Copious lavage is controversial
• Re-laparotomy
– Best avoided unless good indication
– Best not as a diagnostic approach
– The mortality is very high

16. St Mark's Hospital
and Academic Institute
• Do not operate in the 10 day to 3 month window
– At this stage local control can be achieved if needed

17. St Mark's Hospital
and Academic Institute
Predicting the need for re-laparotomy

18. St Mark's Hospital
and Academic Institute
Abdominal
Compartment
Syndrome

19. St Mark's Hospital
and Academic Institute
Abdominal compartment syndrome
• Open abdomen – conceptual more than evidence based
• Most studies have a high mortality in open abdomen
group

20. St Mark's Hospital
and Academic Institute
The second look laparotomy in ischaemia
• Why?
– to assess further ischaemia
• Does it make a difference?
– Not an evidence based approach
– Potentially increases morbidity
• 71 patients, one needed further resection in one series 57
patients had no second look as they had a stoma
• Planned vs on demand

21. St Mark's Hospital
and Academic Institute
Published studies on 2nd look

22. St Mark's Hospital
and Academic Institute
• Second look laparotomy to check the join
– Not accurate to determine or predict leak
• Given the sick patient and associated mortality a
pragmatic argument can be made to perform one life
saving operation

23. St Mark's Hospital
and Academic Institute
‘When you come to the end of the rope tie a knot and
hang on!’
Franklin D Rossevelt

24. St Mark's Hospital
and Academic Institute
Operate when the patient is in the best
possible condition and wounds
optimised

25. St Mark's Hospital
and Academic Institute
Subsequent course
• Radiological mapping – unable to
confirm integrity of rectal anastomosis
• Readmitted 17/10/11 for surgery on
18/10/11
• End result - 140cm of SB to most of
colon and end colostomy. Two
anastomoses. Strattice to abdominal wall

26. St Mark's Hospital
and Academic Institute
Subsequent course
• HDU x 1 week
• Post op ileus and UTI
• “Discharged” home 09/11/11 – day 22
• Discharged from Nutrition clinic 22/12/11
85kg off PN
• Discharged from Surgical clinic 04/01/12

27. St Mark's Hospital
and Academic Institute
Conclusions
• Re-operation is not always the answer and decision
making should be multidisciplinary
• Fixing the problem is not always the answer sometimes
damage control is prudent
• The consequences of any actions can be corrected
when conditions are optimal