More Info On Jude's Surgery

So I imagine some of you may be curious about the particulars of Jude's surgery and exactly what the doctors found once they opened him up. Although my medical knowledge is extremely limited and we are still a little unclear on the sequencing of a few things ourselves, this is the gist of what we know:

In a nutshell...

Jude's surgery was done through two surgical sites: An abdominal incision was made on his left side, and a second incision was made on the left side of his chest. The organs that were in Jude's chest at the time of surgery -- the bowel and part of his liver -- were moved down into his abdomen, and the hernia in his diaphragm was repaired. As we were told, the right side of Jude's diaphragm was intact, but there wasn't much on the left side. There was only a small band of diaphragm tissue on the left side, but by stretching it and also using a biological AlloDerm patch, the surgeon was able to close the hole. A chest tube was inserted into the left side of Jude's chest to drain fluid that will accumulate post-operation, the surgical sites were sutured, then he was brought back up to the NICU.

A more detailed account...

As indicated in a post earlier today, when the surgeon began the procedure, he discovered that Jude's bowel was matted and fused together by adhesions, which are bands of tissue that can connect loops of the intestines together, or to other organs or the abdominal wall. The surgical team was reportedly distressed by this finding. Attempting to disentangle the bowel by pulling or cutting the adhesions would certainly have caused bleeding, which could have been fatal to Jude, so the surgeon would later move the bowel down below the diaphragm as it was. (The adhesions may have fused the bowel to some other surrounding tissues, but we're not 100% clear on whether that was the case.)

There are a number of things that can cause adhesions to form, although abdominal surgery is the most common culprit. In Jude's case, the infection and subsequent inflammation that recently occurred in his abdomen, and more specifically in his peritoneal cavity (i.e. peritonitis), is what we understand to be the likely cause of all the adhesions among his bowel.

Several weeks ago, when Jude's umbilical venous catheter eroded and deposited his IV nutrition and intralipids (fat emulsion, which is part of Jude's "diet") into the peritoneal space along his abdominal wall, the fluid actually traveled up into the pleural space along his chest wall, too. (I'm unclear on whether the bowel actually came into direct contact with this fluid, but perhaps that's beside the point.) Because of this accumulation of foreign fluid, his abdomen became inflamed and distended, which probably spurred the creation of the adhesions along the bowel.

At the beginning of the surgery, the surgeon apparently couldn't even get a clear look at the diaphragm from the vantage point(s) available to him at that time: Between the bowel and Jude's enlarged liver, his view was effectively blocked. (Side note: Jude's enlarged liver was not unexpected, as the surgeon told us that most patients that go on ECMO have liver enlargement.)

At this point, it sounds like the surgery slowed down considerably, as the team recognized that they needed to take a few additional preparatory steps before they proceeded any further. Additional units of blood were ordered, additional catheters were inserted (I think) to offer additional lines of access, and antibiotics were ordered. The antibiotics were readied because the surgeon found evidence of infection in Jude's peritoneal cavity. This infection wasn't in his bloodstream, so he wasn't septic, but it needed to be flushed and beginning treatment with antibiotics was in order. (A tissue sample was taken and cultured, which grew a gram positive cocci very quickly. This might be a lingering trace of the staph aureus bug that Jude was treated for previously.) Jude's neonatologist and his nurse sought us out in the surgery waiting room to tell us about the situation, i.e. that it was very serious and that the surgery would probably be much longer than the 2-3 hours originally expected. At approximately 11 am, the surgical team got started again.

Around 11:30 am, I called Jude's nurse, and she indicated that things were going well, as indicated in my earlier post. Jude was weathering the surgery well: He was stable and he hadn't lost a lot of blood. The part of Jude's liver that was in his chest had already been moved back down, and the diaphragm was beginning to come into view.

After the bowel was moved down, the surgeons were able to turn their attention to repairing Jude's diaphragm. Upon closer inspection, they noticed that there was a strip of diaphragm tissue on the left side that they would be able to work with. They stretched the tissue across part of the defect, then they used a biological patch called AlloDerm to close up the remainder. Another kind of patch called a GORE-TEX patch would have been used, but the surgeon indicated that particular patch could hold onto bacteria from the infection in Jude's peritoneal cavity, so he decided on the AlloDerm, which apparently was the safer option and would be more conducive to treating the remaining infection in Jude's abdomen. The only concern is that whereas the GORE-TEX patch is permanent, an AlloDerm patch can disintegrate over time and potentially put Jude at risk for reherniation. Our hope is that scar tissue will slowly help close the space that's presently occupied by the patch and that we won't ever have to worry about reherniation in the months and years to come.

Also, at some point during the surgery, a chest tube was inserted in or near the incision on Jude's chest, which will drain fluid as it accumulates in his chest in the days to come.

Amazingly, the surgery was over after roughly an hour and a half! The surgeon deferred on trying to disentangle Jude's bowel because of the high risk of bleeding, so that shortened the surgery a bit. However, when the surgeon talked to us after the procedure, he joked that he also had his "A-Team" during the surgery. He apparently called several other physicians to provide various kinds of assistance, and another pediatric surgeon scrubbed in to help, too. In short, Jude had a lot of talented people taking care of him. :)

Now that Jude is back in the NICU, as indicated in a previous post, he'll have a number of additional hurdles to clear. In the next day or two, pain management and fluid management may be the biggest issues. The specter of pulmonary hypertension is still lurking as well, and although the evidence up to this point has suggested that it has largely improved since  Jude went on ECMO, we're continuing to pray that it'll be kept at bay and that he will be protected from it. We'll keep everyone posted on Jude's condition as he now starts on the road to recovery following surgery.

Rose and I continue to be amazed at how God is working through this situation. As a friend reminded us today, the Lord has plans for Jude that will be accomplished, and even though we love our little man so intensely, He loves him more than we ever could. We pray that these truths will be written on our hearts as continue to move forward, regardless of how things work out.

Thank you all so much for your prayers today. We know that our God hears our prayers, and from what we can gather, there must have been thousands of people on their knees praying for Jude's healing and for God's glorification through his little life. It's humbling that God would lay our son and his welfare on the hearts of so many. In addition to the miraculous ways in which God has worked healing in Jude, He has been SO good to us through the love and fellowship of others -- our families, our brothers and sisters in Christ, friends old and new, coworkers and customers, doctors and nurses, acquaintances and those who do not even know us personally but who pray for Jude nonetheless. God has been exceedingly generous to us through others, blessing us materially and spiritually beyond belief.

Now, at the end of such a long and emotionally exhausting day, we're hoping to get some rest. Thank you all again for your prayers and support. And thank you, God, for your grace. Through the gospel of our Lord Jesus Christ, You have rescued us and set us on solid ground when all other ground is sinking sand and our circumstances are so overwhelming. Help us keep our hope only in Jesus and in nothing else as we move forward.

    And we know that for those who love God all things work together for good, for those who are called according to his purpose.
(Romans 8:28)

    Therefore, since we are surrounded by so great a cloud of witnesses, let us also lay aside every weight, and sin which clings so closely, and let us run with endurance the race that is set before us, looking to Jesus, the founder and perfecter of our faith, who for the joy that was set before him endured the cross, despising the shame, and is seated at the right hand of the throne of God.
(Hebrews 12:1-2)