Date of Medical Observation:

June 2006

Narration

First time to do appendectomy all by myself, I was so delighted. There were four patient for appendectomy in my list. My seniors instructed me to do as many as I could.

After finishing the first case which was unremarkable. I proceeded with the second case. He was a 15 year old male, who was supposed to be the last from the list among the four.

My seniors decided to do him first because he can not tolerate the pain any longer more than the other two patient.

He was yelling along the hallway of the ward riding a wheel chair. He was begging me to take him first.

I examined him prior to transferring to the operating room. Upon inspection I noticed a visible elevation over the right paraumbilical area of his abdomen. Then on palpation I perceived a huge oval mass.

 “ Putok na ito..” I told to my self, thinking that the appendix was already ruptured and walled off by the omentum. I did not bother to ask a brief history again before doing the procedure. At the OR table the patient was restless. He was so much in pain.

It was the first time I saw such patient with appendicitis in such so severe pain. Pain that was surprisingly not congruent with tenderness upon palpation.

 “Cutting po doktora..” I told my anesthesiologist as I started the procedure. I just made my incision exactly just beneath the huge mass I described earlier. Then I entered the peritoneum. I was expecting entangled omentum to appear first but there was none.

The mass that was actually visible outside was a distended bowel. At that point in time I was still focusing on an appendicitis. I just bothered to search for the appendix which I found very difficult because of the distended bowel covering my entire incision.

After a couple of  twists and turns of my retractors I finally found my appendix. It was in congestive stage hiding beneath the bowel loops pushed inward in the mid abdomen. Its position was so deep that I can not able to reach it totally.

As I blind searched the distended bowel with my finger I noticed a more tight distension on its mesenteric side.  Considering everything from the symptoms to intra-operative findings, I doubted my pre-op diagnosis. There must be other pathology other than appendicitis, I thought.

This was the time I called my seniors for help. There might be  some sort of intestinal obstruction. May be a volvolus, I guessed.

My seniors came. We extended the incision and explored the abdomen.

To our surprise it was an intussusception.

            Approximately 40 cm of non viable, gangrenous portion of the  ileum was telescoped on itself. A meckel’s diverticulum was found 50 cm from the ileocecal junction and was thought to be the lead point of the intussusception.

<!--[if !supportLists]-->n<!--[endif]-->Insight, Discovery, Stimulus

<!--[if !supportLists]-->n<!--[endif]-->Physical, Emotional, Psycho-social

Another lessons learned.

            “Always take complete history.”

                        We must illicit a complete history when dealing with every patient. We must always cling to the premise that patients do not understand what really going on inside their body. We can not really get complete or enough information unless we ask.

“Endorse patients properly”

                        In our present setting, patients are sometimes seen and admitted by one group  then for some reason will be endorse eventually to other group. Just like what we had in our narration. Patient should be endorsed with every detail of his history and PE findings.

“ Take a brief history and physical examination again immediately prior to operation.”

            These were my short comings.. I stood as the surgeon. I did the operation with out even knowing the history of the patient.

            Yes, I did examined him prior the operation. Still, I failed to decipher what was really obvious on my PE was actually the Dance’s sign of intussusception.

            “Dance's sign is the pathognomonic physical finding in  intussusception, an elongated mass in the right upper quadrant or epigastrium with an absence of bowel in the right lower quadrant “

 “ When in doubt always ask for help.”

            I wonder how bad it could become if I did not called my seniors for help.

            At that point in time when I was searching for the appendix. My thoughts then was focused only on doing an appendectomy. Just find the appendix and remove it. I could have killed my patient if I did so.

END