Page 19 of 73
12:27. DISTURBANCES OF TURN OF INTESTINES
Incomplete turn is observed at disturbance of normal rotation of a gut and its fixing in an abdominal cavity. Turn takes place the following stages in normal conditions: 1) from situation in the middle of an abdominal cavity (under a stomach) the caecum moves to the right lower quadrant of a stomach, rotating counterclockwise around an upper mesenteric artery, as around an axis; 2) other departments of a large intestine located at the left follow for blind, passing at first into the right upper quadrant, and then into the right lower quadrant; 3) after completion of turn the descending and ascending gut is fixed to a back wall of an abdominal cavity by means of a mesentery from Treyts's team slantwise down to a caecum. In certain cases turn comes to the end completely, but the mesentery is underdeveloped owing to what mobility of a small and large intestine is broken.
The most frequent disturbance of turn consists that the caecum does not move to the right lower quadrant of a stomach, and sheaves fixing it press a duodenum, causing impassability (fig. 12-13). Owing to shortening of a mesentery of a small bowel in the field of upper mesenteric vessels there is torsion of guts which is shown as the acute or tranzitorny impassability of intestines passing sometimes into strangulyatsionny.
Fig. 12-13. The impassability mechanism at incomplete turn of intestines. The dotted line showed the correct provision of a caecum. At incomplete turn of a sheaf squeeze a dvevadtsatiperstpy gut, and the shortened mesentery promotes torsion of a middle part of intestines. (From: Nixon H. H., ODonnel B.: The Essentials of Pediatric Surgery. Philadelphia, J. B. Lippincott, 1961.)
Impassability begins in upper part of a duodenum, and then takes the lower end, loops. Torsion of guts is found approximately in a half of the patients operated concerning impassability if the caecum at them is in the right upper quadrant of a stomach. At this pathology symptoms of acute or passing impassability of intestines can be observed already at the birth or on the first year of life. In some cases the wrong turn of intestines is clinically shown as a Gee's disease which gives in to surgical correction. At total absence of turn torsion of a small bowel, bifurcation of a stomach, umbilical hernia, phrenic hernia of Bokhdalek can be observed. Wrong: turn is followed by a ring-shaped pancreas, an atresia and a stenosis of a duodenum.
On survey roentgenograms unusual nature of distribution of gas in intestines is visible; the barium enema confirms the abnormal provision of a caecum. At acute impassability the diagnosis is made during an urgent laparotomy; the only additional research — the survey roentgenogram at vertical position of the patient allowing to see levels of liquid and gas.
At a laparotomy eliminate torsion of guts, dissect the tyazh pressing a duodenum, straighten a large intestine and fix in the left half of an abdominal cavity, and a small bowel — in right. After operation carry out active therapy to warn shock and to recover water-salt balance.