Large Bowel Obstruction

David M. Schwartzberg

David Liska

Perioperative Considerations

Large bowel obstruction (LBO) etiologies include malignancy, inflammatory conditions (eg, diverticulitis, inflammatory bowel disease), volvulus, radiation, and pseudo-obstruction.
Consideration should be given to urgent (eg, ischemia, perforation, sepsis) and elective conditions.
Complete versus partial obstruction often times will guide management.
In the setting of malignant disease, the decision for operative or medical management may depend on life expectancy, goals of care, and extent of disease.
- Left-sided lesions are more prone to presenting with obstruction than right.
- Left-sided lesions may be treated with resection, diversion, or stenting.
- Right-sided lesions are often best treated with resection and anastomosis, although diversion is occasionally required (eg, malnutrition, comorbidities, bowel ischemia, peritonitis).
Diversion versus resection also depends on many of the same factors as above.

Positioning

Modified lithotomy position and Lloyd-Davis position
Arms out or tucked, pending an open or laparoscopic approach
Bilateral ureteral stents (as indicated)
Skin preparation for the abdomen
All extremities should be properly positioned and padded.
The patient pelvis should be placed on the edge of the operative table, with padding underneath the sacrum.
Orogastric tube, Foley catheter, and appropriate lines and monitors

LAPAROSCOPIC DIVERTING LOOP ILEOSTOMY

Perioperative Considerations

Specific Equipment

5-mm 30-degree laparoscope
Wound protector (typical size: small, 2.5-6 cm)
One 12-mm balloon trocar (without obturator)
Small silastic drain (to secure the 12 trocar in the wound protector) or wound protector cap
Two 5-mm trocars
Two atraumatic bowel graspers
5-mm monopolar laparoscopic scissors
3-0 chromic and 3-0 absorbable braided suture and/or surgical marker to mark proximal and distal orientation of bowel
4-0 absorbable monofilament and steri-strips to close port sites
Small stoma rod
3-0 chromic sutures to mature stoma
Ostomy appliance

Technique

A dime-sized disc of skin is incised with a #15 blade scalpel or electrocautery at the premarked ileostomy site (Fig. 37-1).
The subcutaneous fat is vertically incised with electrocautery, while right-angle retractors (Crile retractors) provide exposure (Fig. 37-2).

FIGURE 37-1 ▪ Skin incision for an ileostomy. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

FIGURE 37-2 ▪ Division of the anterior fascia exposing the rectus muscles. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
The anterior fascia of the rectus sheath is exposed and incised for 3-4 cm with electrocautery, while Crile retractors provide exposure.

Once through the fascia, a large Kelly clamp is used to bluntly separate the fibers of the rectus muscle; and the Crile retractors are readjusted to retract the muscle, thereby exposing the posterior sheath (Fig. 37-3).

FIGURE 37-3 ▪ The rectus muscles are bluntly spread apart to expose the posterior fascia. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Two tonsils are used to elevate the posterior sheath.
- The posterior sheath is divided sharply with a Metzenbaum scissor.
- Note the size of the fascia defect should admit the surgeons 1.5 fingers for ileostomy and 2 for a colostomy.
A finger is placed into the peritoneum and swept for adhesions.

If there are no adhesions, a small wound protector is placed, and a finger again swept to ensure no bowel or omentum is incorporated into wound protector.
A 12-mm inflated balloon trocar is placed into the wound protector, and the silastic drain is used to secure the wound protector around the trocar.
Pneumoperitoneum is established, and the left lower quadrant (LLQ) 5-mm port placed under direct vision lateral to the epigastric vessels, followed by a left upper quadrant port.

The abdomen and the pelvis are examined for occult pathology, and pictures taken to document the tumor burden.
Beware for proximal (ie, right-sided) perforation with an acute left-sided obstruction and competent ileocecal valve.
If needed, adhesiolysis is performed using monopolar laparoscopic scissors.
The ileocecal junction is identified, and a loop of ileum approximately 20 cm proximal to the ileocecal valve chosen to be the ileostomy site.
- The future-ileostomy site should be tension free when lifted to the anterior abdominal wall.
At the site selected for the ileostomy, the bowel is marked with electrocautery or a series of stitches to confirm proximal and distal to maintain orientation and avoid a twist.
The 5-mm laparoscope is moved to the LLQ port, and a bowel grasper is then placed in the 12-mm trocar to grasp the bowel while maintaining the correct orientation.
Pneumoperitoneum is carefully released, and the site of the ileostomy carefully brought extracorporeally through the wound protector while meticulously maintaining the proper bowel orientation without any twisting of the mesentery.
Brown (chromic) and blue (absorbable braided), or long and short, stitches are placed to mark distal (brown/short) and proximal (blue/long) (Fig. 37-4).

FIGURE 37-4 ▪ Sutures mark the proper orientation of the loop ileostomy. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
The laparoscopic bowel grasper is replaced with a Babcock clamp, and the wound protector carefully released and pulled up and over the bowel and Babcock.
A small tunnel is created with a Kelly at the bowel-mesentery interface of the eviscerated bowel, and a small stoma rod placed and temporarily secured with two Babcock clamps.
The port sites are closed with 4-0 absorbable monofilament, steri-strips, and nonocclusive bandages.

The ileostomy is opened asymmetrically with the distal limb being just above the level of the skin and allowing for sufficient bowel length to spout the proximal limb (Fig. 37-5).

FIGURE 37-5 ▪ A. Rod is placed under the loop ileostomy and the distal bowel is opened. B. Stoma is matured in a Brooke fashion with full thickness of the bowel, serosa of the bowel and the dermis. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

The efferent/distal limb is sutured in three places, full thickness from bowel lumen (at 6, 4, and 8 o’clock positions) to the dermis, not including the epidermis.
The afferent/proximal limb is then spouted.
- Three sutures are placed, full thickness from the bowel wall (at 12, 10, and 2 o’clock positions) to the dermis and clamped (Fig. 37-6).
- The back of Adson forceps is used to spout the distal bowel as the three sutures are tied sequentially.
  
  FIGURE 37-6 ▪ Stoma maturation. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
The stoma appliance is placed.
The stoma rod is removed on postoperative day 2.