A Surprise in Obstetric Theatres

This may come as a surprise to those who bemoan the stress, unpredictability and long hours, but it was refreshingly great to be on-call last week! Predictably there were frustrations, as I found myself frequently lost in this new hospital, constantly ignorant of how the system works and rather peeved at being left high and dry by a rota gap for the on-call SHO on two days. But in general it was good to be back on the horse, attempting to sift through and make sense of huge numbers of patients with belly pain, vomiting and bleeding that were coming at me from all directions, and trying to determine who needed an operation and in what order.

One of the highlights, having just unscrubbed after finishing a particularly horrendous appendix, was a call from obstetric theatres, asking to attend for a woman having a c-section. Scrubbing in, the Consultant Obstetrician had already got into the peritoneal cavity, and was concerned about a small bowel injury. The patient had had previous c-sections, and there were lots of adhesions to her old scar, with small bowel stuck to the peritoneum where it had just been incised and further adhesions between the bladder and gravid uterus. Obviously due to the said uterus and multiple adhesions, there was very little space to see what exactly was happening, but I very gently and carefully started taking everything down. Failing to really achieve this, and worried about causing an enterotomy, we improved our access by partially dividing the rectus muscles and extending the incision in the sheath laterally. 

Finally I was able to dissect the loop of small bowel free from where it was tenaciously stuck. On inspection however, I was horrified to identify that this wasn't actually a knuckle of bowel, but a single piece - how the hell had I managed to transect across the entire lumen without realising; I had been so careful in my dissection! But thankfully there wasn't any bowel contents leaking out, and on closer inspection I realised that it also wasn't attached to any mesentery. Very odd! Gently pulling, I followed it for several inches to where it disappeared up behind the uterus, thoroughly perplexed as to what I had found. An apparently blind ending piece of small bowel with no associated mesentery - of course, it must be a Meckel's! Satisfyingly, I had managed to detach it without making a hole.

By this point the obstetricians were hopping around and rather keen to get the baby out, so I took a step back whilst they got on with the intended operation. Once done, the view was predictably improved immeasurably, and plain to see was an approximately 6 inch (what happened to the Rule of Two?!?) small bowel diverticulum with an inflamed tip. From then on it was all very straightforward, and we stapled across the base with a GIA Linear Stapler and buried the staple line with 2-0 PDS. By the time I had finished that, I was being bleeped by Main Theatres who were ready with the next appendix.

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