Don't Resect The Bowel

I have been on-call this weekend. For the most part, it has been a dreary affair, with the ward round of the 40-odd surgical patients interspersed only with popping an abscess or two, and trudging to A&E to see the next non-specific abdominal pain that they're not sure what to do with. Fortunately however, the next phone call was a referral for a 74 year old gentleman presenting with abdominal pain, distention and vomiting. The CT demonstrated a closed loop small bowel obstruction, with venous congestion of the affected loop. I got on the phone to the anaesthetist and theatre co-ordinator to give them the good news.

As it was Sunday, and my consultant had only popped in to be briefly acquainted with the new admissions so as not to fall foul of Trust Policy, I let him know what I was up to when the ODP was on their way to retrieve the patient from A&E. Once the anaesthetist had done their bit, I carefully examined the relaxed virgin belly, attempting to palpate anything that had been impossible to feel in the tense and tender abdomen I had examined in A&E. All I could determine was that the upper abdomen seemed somewhat more distended than the lower. This is what makes Emergency General Surgery so exciting! Even with the benefit of a CT scan, all that I really knew was that there was an unhappy loop of small bowel in there somewhere. Would I be able to find the cause, and did I had the skills, knowledge and decision making ability to deal with any surprises lurking down under the abdominal wall? 

Well, they say that the abdominal wall is the only thing separating a surgeon from an accurate diagnosis! So I made a start with the incision of indecision; a trans-linea alba midline cut centred on the umbilicus, using a size 22 blade to swiftly enter the peritoneal cavity. Immediately, distended loops of small bowel were there, wriggling around in a large amount of dirty haemoserous fluid. I began by following the small bowel, and first traced the distended loops the wrong way to reach the DJ flexure. Effecting an about turn, I followed them back in the opposite direction, my scrub-nurse assistant helping to control the ever growing pile of entrails. In due course, I came across the problem; a band adhesion between the greater omentum and the right lateral wall of the peritoneal cavity. Thank goodness; something I could most certainly cope with! The small bowel had wriggled into this hole and been constricted, obstructing the lumen and cutting off its blood supply. The affected 30cm loop of proximal ileum was erythematous and congested, with thickening of the associated mesentery. Proximal to the adhesion, the small bowel was tense, red and distended. Distally it was collapsed and pale. Relieved to have found a pathology that I could competently deal with, I snipped the adhesion, releasing the affected loop. 

After 5 minutes of the affected loop relaxing in hot packs with the anaesthetist providing 100% O2, I had another look. I was disappointed to conclude that it still looked decidedly unhappy, and flicking it provoked no reassuring wriggles of peristalsis. I made the decision to chop it out, and called for a GIA  stapler. At that moment, my consultant poked his head in, and peered over my shoulder to see what I had been up to. He suggested that I give the bowel a reprieve and another 5 minutes in the hot packs. I did as he instructed, and on the second inspection I was surprised to find strong peristalsis and improved colour, with bowel content flowing into the previously collapsed loops of bowel, and strong pulsation now palpable in mesentery. No need to risk a resection after all! Satisfied, my consultant left to find some coffee.

All that was left to do was to inspect the rest of the abdomen, effecting a systematic inspection and palpation of the rectosigmoid, left, transverse and right colon, the caecum and another look at the small bowel and it's mesentery from the ileocaecal valve to the ligament of Treitz. A peer into the pelvis and squeeze of the liver and spleen convinced me that all there was left to do was wash out and close.

Afterwards, in the coffee room my consultant asked why I had been so quick to condemn the small bowel to a resection? I remonstrated that before he had walked in, it had not given me any reassuring indication that it was viable, and I had obviously been disinclined to drop a loop of dead bowel back in to cause problems later. He gave me a knowing look, and explained that after few more years of sleepless nights, waking to fret over whether that knot had been tied securely enough, or perhaps that space between the sutures had been just a little too far, I would not be so quick to resect the bowel. The reason for this is that a resection inevitably means that you have to create an anastomosis! These seemed like wise words. An additional 5 minutes longer than I had felt was sufficient to wait, and I had been more than happy to hand back the unused GIA stapler, and enjoy a restful night.