Written Stories

First Exploratory Laparotomy In Karnali Zone

15 Sep, 2016 By: Dr Jwala Thapa

Late in the night, the phone rang and as expected that was a call from the hospital. Two doctors including myself went to attend the case. The case was a female complaining of pain abdomen since 2 days. Her pain was of moderate degree and she had no other complains. The emergency staff on the duty had given injection Aciloc and Buscopan to her but she said that there was no improvement and the pain was increasing. I tried to take the detail history of the patient, from her and her family member but could not find the relevant point.

Meanwhile we started to do the clinical examination and found that there was no abnormality except tenderness on the right iliac region and I felt she looked slightly pale .As the patient was of reproductive age, I took her menstrual and obstetric history as well but she said that she had no abnormality. So we decided to send   all the essential laboratory investigations such as blood tests and urine test. We also planned to do USG abdomen and pelvis. The patient was given painkiller and was prepared for the ultrasonography. The doctor did the USG and found that there was minimal collection of fluid behind the uterus. Rest was fine. I was doubtful about the patient so I send the urine pregnancy test of the patient as well. We were waiting for the reports to come and at that time the patient was also doing fine because of the effect of the painkiller. Finally the reports came, her hemoglobin was 11 gm% and her pregnancy test was positive.

We now started to think that she might be having ectopic pregnancy as there was fluid collection on USG and she was pregnancy positive. I talked with patient about that but she had no idea. We could not afford to take a chance as our hospital is not well equipped to manage ectopic pregnancy; so we decided to refer her to Nepalgunj. She was referred, but unluckily the weather was so bad the plane didn’t come and she could not go. We decided to manage her conservatively with painkillers and fluids and hoped that the plane would come the next day. There was no severe complain from the patient at night but early in the morning we were informed that she was complaining of pain and was agitated also. We attended her immediately, found that her vitals were unstable and there were signs of shock. She looked alarmingly pale also, so we immediately send for the hemoglobin. We resuscitated her, the report showed that she had only 6 gm % of hemoglobin.
We were really alarmed as there is no provision of storage of blood in blood bank system in jumla .We had to arrange blood as soon as possible and send her immediately to higher centre for laparotomy as there was sign of internal bleeding as evidenced by her condition as well as her report. The patient party found out that the plane wouldn’t come that day also. Now it was us that had to manage that case at any cost. There was no history of such cases being done in the hospital previously so we were quite tensed. There was a senior volunteer doctor at that time in the hospital so I, being an ASBA trained doctor, along with her decided to operate the patient as there was no alternative we could do. We needed at least four pints of blood to start the operation as her hemoglobin was very low and there was likely chance of hemorrhage. Luckily one of the doctors had the same blood group as the patient and he quickly gave 1 pint of blood and thanks to him we started the operation. As we were doing the operation other volunteers also came to donate their blood.

When we opened the abdomen there was approximately one and a half liters of blood in the abdomen. We suctioned the blood and upon exploring the abdomen found that there was a ruptured corpus luteal cyst in the right ovary. It was explored and then sutured but the main thing was that the bleeding did not control at all. We could not find the source of bleeding. We explored the bowel as well and possibly did all that we could do from our experience but there was still some bleeding that we could not control. Meanwhile the patient received 3 pints of blood.

The operation was done for almost 4 hrs and though the patient was stable there was still collection of blood in the abdominal cavity. As there was no point still exploring as it could  cause more damage to organs and the bowel, so we decided to put a drain in situ and close the abdomen and sent her to post op room. At night she had mild fever and vomiting tendency, otherwise she was stable. She received altogether 6 pints of blood transfusion. In the morning, patient was quite stable and hemoglobin was sent. The report came and it was 10 gm %. But there was still some amount of blood collected in the drain bag. The collected blood was around 200 ml in the morning and the blood was still coming from the drain site so we decided to continue the drain. Later in the evening that day we started oral fluids and the patient tolerated it.

There was approximately 850 ml of collection in the drain bag in 48 hours. The next day there was minimal collection in the bag so we took out the drain. The wound was also healthy and most importantly the patient was very fine and told us that she had no complains. She remained in the hospital for 1 week and was discharged as she recovered very well. She still comes for follow up and looking at her we all feel very good that our hard work and perseverance paid so well. In a health set up and remote place like this where there is not much facilities and no senior doctors, I feel this kind of case and experience in one’s life really makes one  strong and more tactful in the longer run.

Prepared by:
Dr Jwala Thapa
Medical Officer Karnali Zonal Hospital

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