Surgical case # 01

A 70 year old male presented for reversal of ileostomy done due to strangulated umbilical hernia.

H.O.P.C: Patient was in fine health 2 months back than he developed pain in central abdomen along with swelling. The pain was mild initially but progressed to spasmodic diffuse pain throughout abdomen that aggravated with weightlifting and relieved by analgesics but after increasing in intensity was not being relieved by any meds. It was also associated with nausea, fever and vomiting. The pain was not radiating or shifting to any other region. The swelling was initially small in size around golf ball and located in umbilical region but progressed to tennis ball size and increased on straining, weight lifting and was reduced on lying down. On worsening of condition, patient was taken to ER and exploratory laparotomy was done with resection of half feet of gangrenous gut was done 1.5 feet proximal to IC junction with formation of loop ileostomy.
Now, after two months from the operation patient presented with normal working stoma bag and no other complaints for reversal of ileostomy.

Systemic inquiry: Nocturia
Past History: Medical: known c/o of BPH for 10 years taking tamsulin.
Surgical: left herniotomy done 12 years back.
Personal History: Normal sleep, apetite, bowel movements. Nocturia, addiction to beetle nuts.
Blood transfusion: WBCs transfused during Exploratory laparotomy
Allergy: None
Drugs: Tamsulin for 10 years
Family history: No hx of familial diseases.

Examination:
An elderly man of lean built and normal stature well oriented to time, place and person.
Vitals: B.P=130/40 mmHg, Pulse= 90 bpm, Temp= A/F, R.R= 19 br/min, SpO2=97 on room air.
Sub Vitals: C-ve, E-ve, A-ve, J-ve, Lym-ve.
Abdominal examination:
Positive findings: Midline healed scar mark of 7 by 2 cm, diagonal scar mark in Left iliac fossa, visible and palpable pulsations in epigastric region, working stoma with both loops patent and semi solid fecal matter coming from proximal loop.
Inguinal examination:
Positive findings: Oblique healed scar mark in left inguinal region, Globular 6 by 4 cm sized globular swelling in right inguinal region with +ve cough impulse and +ve palpable cough impulse reducible swelling not reaching scrotal apex.
DRE: Unremarkable.

Investigations:
Normal CBC, U/C/E, PSA levels, viral profile negative for Hepatitis B, C and HIV, Loopogram normal, U/S abdomen, inguinoscrotal and pre and post voidal has no positive findings?

1. What is your diagnosis?
2. What should be surgical plan for patient?
3. What is the reason for pulsations in epigastric region?

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