Step 2: Preoperative Considerations
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Patients with small bowel obstructions require careful preoperative evaluation. Neither history, physical exam, nor laboratory evaluation have proven reliable in determining impending ischemia to the intestines. Therefore, a high index of suspicion for operative intervention, especially in complete obstructions, is warranted.
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Plain abdominal films, CT scans, and small bowel follow-throughs are all useful adjuncts in determining whether the obstruction is complete or partial.
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Volume shifts and electrolyte abnormalities can be significant in high-grade small bowel obstructions and should be carefully assessed preoperatively.
Step 3: Operative Steps
1.
Open Resection
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When the decision to operate for small bowel resection has been made, it is critical to communicate the condition of the patient and diagnosis with the anesthesiologist to ensure that all precautions against aspiration are performed.
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Incision: The choice is crucial. A midline laparotomy is typically preferred but should be extended to an area of virgin abdomen to minimize the risk of bowel injury. In some cases a transverse incision at or above the umbilicus can be considered.
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The abdomen cavity is entered without cautery; a scalpel or pair of scissors is preferred.
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Free adhesions along the length of the wound with a Kocher clamp on the fascia and tension and counter tension on the adhesions. ( Figure 29-1 )
Figure 29-1
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Observe the character of the peritoneal fluid and take cultures.
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Sharp dissection of adhesions and identify transition point. ( Figure 29-2 )
