Open Adhesiolysis for Small Bowel Obstruction

Abstract

Enterolysis (lysis of adhesions) is performed for adhesive small bowel obstruction or during entry into the previously operated abdomen. This chapter lists indications, essential steps, technical variations, and complications for this procedure. It provides a detailed template operative dictation note for performing the procedure for small bowel obstruction.

Indications

• Small bowel obstruction

• Adjunct to other surgical procedures (previously operated abdomen)

Essential Steps

• 1. Midline incision.

• 2. Enter the abdomen above or below the old scar if possible.

• 3. Apply traction to adherent loops and divide the adhesions sharply under direct vision.

• 4. Identify point(s) of obstruction.

• 5. Ascertain viability of the bowel.

• 6. Run the small bowel.

• 7. Confirm absence of additional areas of obstruction, injuries, or compromised bowel.

• 8. Repair deserosalized areas or inadvertent enterotomies.

• 9. Check hemostasis.

• 10. Close the abdomen.

Note This Variation

• Repair of enterotomies

Complications

• Recurrent obstruction

• Enterocutaneous fistula

Template Operative Dictation

Preoperative Diagnosis

Small bowel obstruction

Procedure

Exploratory laparotomy and enterolysis

Postoperative Diagnosis

Same

Indications

The patient is a ____-year-old male/female with history of appendectomy/hysterectomy/other abdominal procedure, who presented ____ days ago with picture consistent with partial small bowel obstruction that progressed to complete bowel obstruction unresponsive to conservative measures/complete bowel obstruction/bowel obstruction with tenderness and clinical deterioration/other.

Description of Procedure

An epidural catheter was placed by anesthesia prior to the start of the operation. The patient was placed in the supine position. Time-outs were performed using both preinduction and pre-incision safety checklists to verify correct patient, procedure, site, and additional critical information prior to beginning the procedure. General endotracheal anesthesia was induced. Preoperative antibiotics were given. The abdomen was prepped and draped in the usual sterile fashion.

A vertical midline incision was made from above the previous laparotomy incision down to its most inferior extent/xiphoid to just below the umbilicus/other. This was deepened through the subcutaneous tissues and hemostasis was achieved with electrocautery. The linea alba was identified and incised in a region above the old incision/in the upper abdomen/other and the peritoneal cavity entered with care.

Upon entering the abdominal cavity, there are extensive adhesions of omentum and bowel to the underside of the old incision/more prominent in (specify location). Omentum and loops of bowel were carefully dissected from the underside of the abdominal wall using sharp dissection with Metzenbaum scissors. Careful exploration of the abdomen was then performed (detail findings).

The small bowel was run from the ligament of Treitz to the ileocecal valve. The bowel was noted to be dilated proximally and collapsed distally with a zone of transition (describe location). An adhesive band was noted/multiple adhesions were noted to be obstructing the distal small bowel. All adhesions were divided sharply and all small bowel loops carefully separated. The entire small bowel was then inspected for viability and the absence of any additional obstructing bands. A small patch/patches of deserosalized bowel was/were imbricated with 3-0 silk Lembert sutures/3-0 Vicryl sutures. An inadvertent enterotomy was repaired/enterotomies were repaired in two layers with 3-0 Vicryl and 3-0 silk. Small bowel content was milked proximally to be aspirated by the nasogastric tube and distally into the colon, again confirming patency and integrity throughout its entire length. The abdominal cavity was copiously washed with saline and hemostasis was obtained.

(Optional: Multiple interrupted through-and-through retention sutures of ____were placed.) The fascia was closed with a running suture of ____/a Smead-Jones closure of interrupted ____. The skin was closed with skin staples/subcuticular sutures of ____/other.

A debriefing checklist was completed to share information critical to postoperative care of the patient. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.