NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Q: What options would you consider in the management of this patient? A: Many surgeons prefer this “second-look” operation, a proven, safe method of patient man- agement. The major pitfall in management is delaying the second operation. Clinicians may believe that a patient is doing well after the first operation and does not need the second surgery, when in fact, ischemic bowel is present. Although it may not perforate and make the patient sick for several days, by the time it is evident, they are much sicker. Thus, the delay can significantly jeopardize patients. The primary issue is whether the bowel is viable. If observation does not provide a definitive indication, either resec- tion and reanastomosis or a “second-look” operation is necessary. A “sec- ond-look” operation is a planned reexploration 24 hours later to inspect the questionable bowel. Resection of any ischemic or necrotic bowel followed by anastomosis reestablishes bowel continuity. Case Variation 8.3.2. Crampy abdominal pain and free air in the peritoneal cavity ◆ ◆ Exploration is necessary to resolve this problem. If the free air occurred during observa- tion for a small bowel obstruction, it is most likely due to either an ischemic perforation or perforation due to overexpansion of the bowel. Thus, part of the process of observation includes monitoring the degree of intestinal distention on the radiographs. Q: How might the operative findings differ in the same patient, with free air on abdominal radiograph? A: The operative findings in this patient might be similar to the previous patient’s with the additional finding of a perforation in the distended loop of bowel. This would most likely require resection. Case Variation 8.3.3. Crampy abdominal pain and an inguinal hernia ◆ ◆ This patient has evidence of a small bowel obstruction and bowel within a hernia sac. Urgent exploration is necessary after rapid resuscitation. You decide to explore a patient with an incarcerated inguinal hernia and a small bowel obstruction. Q: What are the options for operative management? A: Management may differ depending on how sick the patient appears. In a relatively stable patient with no signs of systemic illness, exploration through a hernia incision in the groin is appropriate. The surgeon can explore the hernia, inspect the bowel and return it to the peritoneal cavity if viable, and repair the hernia. In a patient who appears ill, exploration through a midline abdominal incision is pre- ferred. This allows a more thorough inspection of the entire bowel. If the bowel is ques- tionable or necrotic, either observation until it is viable or resection and reanastomosis are possible. The surgeon may repair the hernia with mesh if there are no signs of infection or perforation. If there is infection or perforation, a tissue repair without mesh can be per- formed if the patient is stable. Case 8.4 Injury to the Bowel during Lysis of Adhesions You are exploring a 60-year-old with a small bowel obstruction that involves particu- larly dense adhesions. In the process of lysing one, you enter the bowel lumen. SAMPLE