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Laparoscopically Surgery for Colonic Perforation with Peritonitis.

This is the case of a 51 year-old female, that underwent a polypectomy of a polyp in the cecum that was carried out in another clinic, ten hours after that patient began with mild abdominal pain located in the right iliac fossa, the abdomen was soft and tender and no rebound was detected.

Laboratory tests indicated an elevated White cell count of 16 500 with 82.9% neutrophils, patient was hospitalized with the presumptive diagnosis of transmural burn syndrome.

Post polypectomy electrocoagulation syndrome (also known as postpolypectomy syndrome and transmural burn syndrome) refers to the development of abdominal pain, fever, leukocytosis, and peritoneal inflammation in the absence of frank perforation that occurs after polypectomy with electrocoagulation Recognition of postpolypectomy syndrome is important to avoid unnecessary exploratory laparotomy since it resolves with conservative treatment in the majority of patients.

Postpolypectomy syndrome develops when electrical current applied during polypectomy extends past the mucosa into the muscularis propria and serosa, resulting in a transmural burn without perforation . Serosal irritation leads to a localized inflammatory response that manifests clinically as a localized peritonitis.

The second day in the hospital, patient had a severe abdominal paint with felling of shortness of breath, with abrupt onset of acute abdomen with severe generalized abdominal pain, tenderness, and peritoneal signs. Pain was radiated to the shoulder, An abdominal series (supine and upright abdominal x -rays and chest x-rays), showing free air under the diaphragm. The transmural burn syndrome had evolved to colon perforation.

This was managed successfully by exploratory laparoscopy and peritoneal lavage with drainage. The perforation was repaired at a laparoscopy using intracorporeal suturing.

 

 

 

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The fibropurulent exudate are being aspirated

The post surgical period patient had generalized Sepsis that was management with antibiotics and dopamine.

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The exact site of the perforation has been located in the cecum.

Full thickness diathermy injury resulting in delayed perforation at the damage site.

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More images and video clips of the perforation´s hole

Colonoscopy is a powerful diagnostic and therapeutic procedure with a recognized risk of complications ranging from perforation to hemorrhage and septicemia. Perhaps the most dangerous complication associated with this procedure is bowel perforation.

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The hole of the perforation is exposed

Major risks associated with large polypectomy with conventional monopolar snare polypectomy are bleeding and perforation. Bleeding occurs when too little current is used and perforation usually occurs when too much current is used.

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The laparoscopic repair with mechanic suturing stapler is initiated.

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Estas suturas mecánicas además de realizar la sutura cortan el tejido.

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Esta imagen muestra el tejido al derredor de la perforación el cual ha sido extirpado y el agujero suturado con grapas mecánicas.

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En este video se observa el refuerzo de las suturas mecánicas con hilos convencionales.

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Se sigue el proceso de suturar y reforzar el sitio de la perforación.

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Se termina el proceso de refuerzo y se procede a cortar los hilos.

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Se procede a aspirar secreciones provenientes del colon, el líquido corresponde a mezcla del laxante usado para la colonoscopia y restos de heces líquidas.

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Se observa la introducción de uno de los trocares usados en este procedimiento.

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Se observa un mioma uterino

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Otra imagen y video del mioma

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Otra imagen y video del mioma

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Abundantes placas purulentas adheridas a las asas intestinales.

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Hay varias placas fibrinopurulentas, las cuales fueron aspiradas.

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Se le colocaron drenos

La paciente fue manejada con antibióticos, tubo shock séptico, manejado con antibioticos y dopamina, el tercer día se le volvió a realizar otra exploración vía laparoscópica drenándosele escasas secreciones purulentas, evolucionado satisfactoriamente dándosele el alta del hospital al 7 día.

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