Lysis of Adhesions for SBO
What the Examiner Expects
Operative intervention for small bowel obstruction caused by adhesions, involving careful adhesiolysis to relieve the obstruction. The examiner expects you to first attempt nonoperative management (NG tube decompression, IV resuscitation, correction of electrolytes) for partial or early complete obstruction without signs of strangulation. A water-soluble contrast challenge (Gastrografin via NG tube) is both diagnostic and therapeutic — if contrast reaches the colon within 24 hours, the obstruction will likely resolve nonoperatively. Operative indications include peritonitis, signs of strangulation (fever, tachycardia, leukocytosis, localized tenderness, lactic acidosis), closed-loop obstruction on CT, or failure to improve after 48–72 hours of conservative management.
Key Examiner Focus Points
- Most common cause of SBO in developed countries is adhesions from prior surgery
- Initial management: NPO, NG decompression, IV fluids, serial abdominal exams
- Operative indications: peritonitis, strangulation, closed-loop obstruction, failure of conservative management (48–72 hrs)
- Water-soluble contrast (Gastrografin) challenge: if contrast reaches colon by 24 hrs, obstruction likely to resolve
- Run the bowel from ligament of Treitz to ileocecal valve to identify all transition points
Common Curveballs
CT shows a closed-loop obstruction with a whirl sign
This cannot be managed conservatively — take to the OR urgently. Closed-loop obstructions carry a high risk of ischemia and perforation. Evaluate bowel viability after releasing the obstruction.
After lysing adhesions, a segment of bowel is questionable — purple and not peristalcing
Wrap in warm laparotomy pads, wait 15–20 minutes, and reassess. Check for Doppler signals in the mesentery. ICG fluorescence if available. If the bowel does not recover, resect it. When in doubt, resect — leaving dead bowel is a critical error that will result in a failing score.
This is the patient's third SBO episode — they ask about prevention
Adhesion barriers (hyaluronate-carboxymethylcellulose membrane — Seprafilm) may reduce adhesion formation but have limited evidence for preventing SBO. Laparoscopic approach for adhesiolysis may result in fewer new adhesions than open surgery.
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