Open Adhesiolysis Periprocedural Care

Updated: Sep 22, 2017
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Preprocedural Planning

A patient with frank peritoneal signs on abdominal examination, hemodynamic instability, lactic acidosis or an elevated base deficit, and an elevated white blood cell (WBC) count in the context of a small-bowel obstruction is assumed to have a strangulated or dead bowel until the operation proves otherwise. Such a patient needs immediate surgical intervention.

However, if a patient has mild-to-moderate abdominal tenderness, a stable WBC count, no fever, and a distended abdomen, and if water-soluble contrast reaches the cecum on a plain film within 24 hours, there is a very high likelihood that an adhesive small-bowel obstruction will resolve with conservative management.

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Equipment

A standard operating room (OR) with the appropriate personnel and staff is required. The equipment in the OR is that typically needed for any surgical case (eg, a ventilator, other pertinent anesthesia equipment, an operating table, a back-table instrument setup, and a suction and irrigation system).

A full laparotomy tray should be available. Depending on the surgeon’s preference, an electrocautery, an ultrasonic dissector, or other energy devices can be used to separate adhesions during the operation. Gastrointestinal (GI) and vascular staplers may be beneficial, depending on the extent of the operation.

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Patient Preparation

Anesthesia

General anesthesia is essential for the procedure: it ensures a controlled and relaxed patient for the surgeon to work with. Placement of an arterial catheter is often beneficial for real-time blood pressure monitoring. Placement of a Foley catheter in the urinary bladder allows intraoperative assessment of volume status and end-organ perfusion; it can also serve as a landmark for the bladder if the adhesions distort the pelvic anatomy.

Application of a longer-acting local anesthetic (eg, bupivacaine) to the incision site before the incision is beneficial in controlling postoperative pain. Additional modalities, such as incisional continuous local anesthesia delivery devices and epidural infusions, are often used but frequently unnecessary.

Positioning

The patient should be placed in the supine position with the arms securely tucked at the sides. A small pillow should be placed underneath the posterior aspect of the knees, and all of the dependent portions of the body should have appropriately padded support.

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