Selected Case Reports and Personal Experience
R. Hohenfellner
In 1964, I moved from Vienna to Homburg/Saar to take an Associate Professor position in one of the most recognized departments of urology headed by Prof. C.E. Alken. Still on duty at 4 p.m., I received a call from the chief of the surgical department to join him immediately in the emergency room.
At 3 p.m. a 60-year-old gynecologist had a rather exceptional accident in his office in a small town nearby. When he tried to take a seat on his swivel chair in front of his patient, the chair turned over and the metal thread went through his anus high up into his rectum. The emergency team arrived immediately and transferred him, with the iron thread still in place, to the surgical department of the university hospital.
The patient was stable and fully conscious and was placed in a Trendelenburg position on the operating table; the anesthesiologist started with general anesthesia.
The chief of the surgical department accompanied by his senior resident looked at me:
“What is your diagnosis, Mr. Hohenfellner?”
It was a critical question. He was an experienced abdominal surgeon, had served many years during the Second World War in different army hospitals, and had certainly encountered similar stab wound injuries before. He had already placed the patient on the operating table, making it impossible to take an x-ray. With the iron post still in his rectum, moving him was highly risky.
“Well,” I said, “the patient is stable, the emergency lab will arrive soon, the length of the post is unknown, an x-ray cannot be taken, but I want to insert a Foley, Sir.”
I inserted an 18-French Foley with no difficulty and 150 ml of hemorrhagic urine passed.
“What does it tell you?”
“The thread went through the rectum and there is some sort of a bladder injury, maybe a penetrating one, but it is proximal of the prostate, Sir.”
“So what will be the first step?”
Again it was a difficult question for a urologist with almost no experience in rectal and bladder stab wound injuries. However, from my residency in general surgery I remembered a case of severe bleeding during a so-called synchronous rectum resection from the perineal wound performed by two teams. A Mikulicz tampon solved the problem in the end. So, I thought, removing the post may cause severe bleeding.
“The first step, Sir, should be a median laparotomy from the sternum down to the symphysis with inspection of the abdomen. At that time, the anesthesiologist will have enough blood transfusion supplies to keep him stable, when a second team removes the post from below.”
“Let’s scrub!”
He opened the abdomen and there was not much blood inside. The top of the post had perforated the rectum and the bladder above the trigone and then went out through the bladder dome in the rectus muscle. The second team was ready and removed the post. The severe bleeding was immediately stopped by about 2 m of the transrectally inserted Mikulicz tampon.
“It is your turn,” he said and moved to the other side of the table. I opened the back side of the bladder from the dome down to the perforation as in a vesicovaginal fistula. Fortunately, the orifices could be identified within the hemorrhagic edematous bladder mucosa and intubated with ureter catheters. He helped me close the rectal wound with two layers of interrupted catgut and silk sutures. I took a peritoneal graft from the left abdominal wall and fixed it between the rectum and the bladder to secure the overlying suture lines from the rectum and the bladder. Then three layers of a running mucosa, interrupted detrusor suture line, and an extra row of peritoneal sutures closed the bladder. A cystostomy tube was inserted.
“Why this?” he asked.
“Well, Sir, the running mucosa suture line is the hemostatic one. Postoperatively, if the small bowel and the peritoneal cavity become distended the peritoneum overlying the bladder will also distend and the bladder suture line will probably be disrupted if it was closed by a single-layer suture line.”
“Have you seen this before?”
“Yes, Sir, in a young lady with a bladder rupture following a car accident. On day 5, the abdomen distended and suture insufficiency ensued, and she had to be operated again.”
“And what is the next step?”
“Well, Sir, I have not much experience but a right-side colostomy may protect the rectal suture line.”
He performed the colostomy and the postoperative course was uneventful. The Mikulicz tampon was removed with the patient under general anesthesia on the 5th day and the bladder catheter 10 days later.
The voiding cystourethrogram was normal, the cystostomy was removed and the patient went home for 3 months, when finally the colostomy was closed.
Today a CT would probably be the first diagnostic step but with the same therapeutic strategy.
Still today the gynecologist’s present is on my desk: a small silver dish with the engraving “Thank you”.
But one question remains. How does one cross the ocean with no navigational equipment? With lots of luck.