![]() ![]() Discharge was on postoperative day 28 with removal of tubes on postoperative day 54 and the patient was able to make a full recovery. The procedure was well-tolerated and the patient was discharged with T-tube in place. A 16-French T-tube was placed in the common bile duct and two large #24 Jackson-Pratt tubes were placed in the vicinity. Open cholescystectomy with intraoperative cholangiogram was performed, isolating extravasation from the common bile duct. Injury was discovered incidentally on exploratory laparotomy post endovascular repair of abdominal thoracic aortic rupture. This case demonstrates a 46 year-old-male involved in a head on motor vehicle collision, sustaining blunt force abdominal trauma resulting in partial transection of the common bile duct. These cases are often difficult to identify, primarily as they are complicated by trauma patients exhibiting more immediate and obviously life-threatening injuries. The small intestine swung well toward the region of the gall bladder, but there was no obstruction.Blunt force trauma to the extrahepatic biliary ductal system as a cause of avulsion is an uncommon injury associated with wide variability in prognosis. This was a most unusual position, but there was no definite pathology revealed. The pylorus was negative, the duodenum swung to the right, and the first portion turned downward. ![]() The stomach was poor in tone, and emptied in 6 hours. Roentgen Examination.-Roentgenographically, we found that the gall bladder filled and emptied well. She was especially tender over the right abdomen, but no mass was palpable. Present Condition.-The patient was a tall, flabby looking woman, whose average weight was 128 pounds. Six or seven years before she was referred to us, she began to have pain in the right side of the abdomen, gas, constipation, pain and indigestion associated with meals. She also had had an operation for some uterine disorder. Two years after the appendectomy she passed some kidney stones, had a bladder infection, and was operated upon for a kidney suspension. Previous History.-She had had an appendectomy twenty-five years previous to the present examination. She complained of pain in the right upper quadrant, and was annoyed by gas and constipation. W., white, widow, aged 57 years, was referred to us for gastro-intestinal examination, in February, 1930. Connective tissue connects this part of the colon to the anterior pararenal fascia, descending part of the duodenum (D2) and head of pancreas.It also creates an impression on the inferior surface of the liver. Most authors agree that the therapy should follow the same lines as that for visceroptosis, and that surgical relief is to be considered only as a last resort. Right colic flexure (or hepatic flexure) is used to describe the bend in the colon as the ascending colon continues as the transverse colon. There have perhaps been three cases analogous to ours which have been reported since 1920. Just (2) reports three more cases, one permanent and two temporary. Two were reported by Trémolières and Pierron (7), but neither one was diagnosed until operation. A review of the literature since that date has revealed only a few more such cases. At that time, only one other case could be found. In 1920, Swezey and Black (6) reported a similar case which was detected by one of us in the diagnosis of routine chest roentgenograms. The condition was first described roentgenographically in 1899 by Béclère (4), and quoted by Trémolières and Pierron (7) and Just (2), but Curschmann (5) described it fully in 1894 in his classic monograph on the subject. The etiology is to be found in defective embryological development (2). Whether the condition is due to increased length and consequent overlapping or just to malposition, it is undoubtedly anomalous. There is a type of redundant colon which shows this same interposition of the colon between the diaphragm and the liver, and which may be permanent or temporary (2, 3). The one which we wish to present is of a kind recognized by various names, but most descriptively termed (by the Continental authors) “hepato-diaphragmatic interposition of the colon” (1, 2, and 7). Anomalies of the hepatic flexure of the colon are not as common as the wealth of literature on the subject would lead one to expect.
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