NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Figure 8-8: Hartmann procedure for diverticulitis: primary resection for diverticulitis of the colon. The affected segment (clamp attached) has been divided at its distal end. In a primary anastomosis, the proximal margin (dotted line) is transected and the bowel attached end to end. In a two-stage procedure, a colostomy is constructed at the proximal margin with the distal stump oversewn (Hartmann procedure, as shown) and the stump is left in the pelvis. The distal stump may be brought to the surface as a mucous fistula if there is concern about blood supply. The second stage consists of colostomy takedown and anastomosis. (From Hinkle JL, Cheever KH. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing , 14th ed. Wolters Kluwer Health; 2017, Fig. 47-4.)

Case Variation 8.7.13. Necrosis of the intestines from the ligament of Treitz to the transverse colon ◆ ◆ In the majority of cases, this is a dire situation. Consideration for closure of the abdomen without resection should be considered in older patients and patients with significant co- morbid conditions, thus allowing patients to succumb to the illness. Surgical resection may be appropriate in younger individuals. Resection of the majority of bowel is appropriate in these patients, leaving patients with a short bowel syndrome and the need for chronic total parenteral nutrition (TPN) or small bowel transplantation. ◆ ◆ Resection of the necrotic bowel back to healthy edge is necessary, with reanastomosis performed under favorable conditions. If there is doubt as to the viability of the intestine, or the patient is unstable, the intestine can be left in discontinuity, and a “second-look” procedure should be performed the next day. If the patient is not a good candidate for an anastomosis because of comorbidities or health of the intestine, another alternative is a jejunostomy, which allows direct observation of the viability of the bowel. Because SAMPLE Case Variation 8.7.14. Necrosis of 2 ft of jejunum and ischemia of adjacent bowel