Case Files: Stab Wound

Presenting Scenario: 48 year old patient presents with a 2 inch laceration on the right lower quadrant of his abdomen. Patient reports that suspects the stabbing occurred that morning around 4am...it is now 1pm at presentation, due to "dizziness". Patient is lying comfortably on bed, seems to be in no apparent distress, but keeps asking for a telephone to call family.

Trauma Room Decisions: The patient refuses to allow the Doctors to insert their finger into the wound and explore how deep it is. Patient becomes combative any time we try. This leaves us with a difficult decision. Either we take patient to CT scan to see if there are any deep injuries to internal organs that could result in a sudden change in status, or we just rush patient up to the OR (Operating Room) and start the operation there under anesthesia. Decision was made to take patient up to the OR.

Diagnosis: Superficial wound. Yes, we rushed the patient to the OR, put patient under general anesthesia, and then were able to stick our finger in the wound...to find nothing. The wound barely even got through any fat layer.

Surgical Procedure: Stitch up the wound.

Results: Patient is fine. Was offered alcohol and drug counseling due to addictions, but otherwise, is fine.

Note: Picture is not from the actual patient's wound.

Case Files: Orchidopexy

Presenting Scenario: A 7 year old boy presents to the outpatient surgeon due to a referral from the Primary Care Pediatrician. He has a suprapubic lump on the left side. Patient's mother denies pain, nausea, vomiting, diarrhea. On physical exam, there is a palpable lump, easily movable, located just above and lateral to the penis.

Diagnosis: Prepubic undescended testicle on the left side.

Surgical Procedure(s) Ordered: Orchidopexy; the surgeon first makes an incision near the site of the undescended testicle, similar to how he might make an incision to fix a hernia. We carefully dissect through the layers of the fascia and muscle until we reach the testicle. Next, through a series of maneuvers that see the gubernaculum (100 points to whoever defines what this is in the comments) released from the testicle and pushing back the perineum and other structures in order to free up more of the spermatic cord so we can pull the testicle down through the scrotal sac. Finally, we stitch the testicle into place and then stitch the outer skin of the scrotum over it to make it look like normal.


Results: This patient had no surgical complications and is fine post-operatively! However, it should be noted that patients with undescended testicles have an increased risk for testicular cancer - even after we fix the undescended testicle. Therefore, this patient will need to be followed closely for the rest of his life. If there are any signs of the cancer, removal of the testicle will become necessary immediately. Some signs of testicular cancer include:

• A lump or mass in either testicle
• Any enlargement or swelling of a testicle
• A collection of fluid in the scrotum
• A dull ache in the lower abdomen, back, or in the groin
• A feeling of heaviness in the scrotum
• Discomfort or pain in a testicle or in the scrotum
• Enlargement or tenderness of the breasts

Case Files: Laparoscopic Cholecystectomy

Presenting Scenario: Patient presents with complaints of right upper quadrant pain for three days, fever, fatigue, and general malaise.
ER Physician Orders: Refer to Surgical Service.

Diagnosis: Recurrent Cholelithiasis (gallstones in gallbladder).

Surgical Procedures Ordered: Laparascopic Cholecystectomy under General Anesthesia

Laparascopic Cholecystectomy Defined: This is a minimally invasive procedure where four small incisions are made in your abdomen to insert four tubes that give us access into your abdomen for a camera and three other tools, like a cauterizer, and various "grabbing" tools. We use the cauterizer to peel away fat and the abdominal covering around your gallbladder, which is located just under your liver. Then, carefully we continue to peel away, taking care not to damage your arteries and making sure we get all the gallbladder. We then insert a special tool that opens up a small bag, place the gallbladder inside the bag, close the bag (while still inside your abdomen), then we pull the bag out of the biggest incision, where the camera is usually placed.

Case Files: Angiogram and Angioplasty

Presenting Scenario: Patient presents complaining of weakness in both legs with decreased pulse bilaterally in the lower extremities (legs).

ER Physician Orders: Refer to Surgical Service

Surgical Procedures Ordered: Angiogram (see explanation below) with Angioplasty (see explanation below) and possible stent placement. No anesthesia will be used for the angiogram and angioplasty, however, the anesthesiologist must monitor patient's vitals.

Angiogram: Procedure of visualizing blood flow through arteries to assess level of lumen narrowing. In this case, we were visualizing the iliac arteries (near the legs/abdomen). We found some pretty extensive narrowing of the lumen of the artery that leads to the right leg. BUT, we also found that due to chronic stenosis of the artery that leads to the left leg, the patient had extensive vessel growth (anastomoses) to the left leg from the one good vessel for the right leg. Therefore, when the vessel for the right leg became stenosed, the patient experienced problems in both legs.

Angioplasty: Process of getting a small balloon to the site of stenosis in the vessel. We then inflate the balloon with some pressure and let is stay there for a minute or two. We then remove the balloon and use the fluoroscopy to visualize the site of the vessel again. The goal is that the balloon will cause the vessel to stay open. It is not uncommon, however, to have restenosis at a later date.

Results: In this case, we found that the vessel was fixed successfully following angioplasty, therefore no stent placement was necessary. Patient can be discharged within the day.