In cases of surgically induced adhesive bowel obstruction, the original incision should be used as much as possible, with one end of the incision longer than the original incision to allow smooth access to the abdominal cavity, but special attention should be paid to the fact that the subperitoneum beyond the original incision is not necessarily free of adhesions and care should be taken. After entering the abdomen, the peritoneum under the incision is cut in its entirety, so the finger-accessible area should be explored for adhesions to determine the strategy for opening the abdomen. If the adhesions are loose, they can be pushed away with the fingers.
If the adhesions are tight, the area of adhesions should be bypassed to the side, and the incision should be widened and the subincisional adhesions separated under direct vision.
If the adhesions are too extensive, the incision should be enlarged towards the already entered abdominal end to separate the adhesions.
If the adhesions are too extensive to enter the abdominal cavity, a low-power incision of the posterior rectus abdominis sheath with an electric knife can be used to separate the peritoneum under direct vision and enter the abdomen.
After opening the abdomen, the adhesions should be further explored, and the fibrous cord compression should be removed by clamping first, and the cord should be removed completely after releasing the intestinal tube compression. Note that the end of the cord near the intestinal canal is mostly the protruding part of the stretched and deformed intestinal canal, which should not be accidentally injured and should be cut off near the peritoneal or mesenteric end.
In case of extensive membranous adhesions, the site of obstruction should be searched along the dilated intestinal canal first, and after releasing the obstruction, the adhesions forming sharp angles or causing distortion of the intestinal canal should be separated, and the obstruction should be solved with minimal separation.
Intestinal adhesion release2 In cases of extensive tight intra-abdominal adhesions, most are due to intra-abdominal infections.
In cases of recent infection, the adhesions are not strong and there is mostly pus or fluid accumulation in the mesenteric space, which can be used as a sign of mesenteric space. If a large pus cavity is found, there may be a rupture or perforation of the adjacent intestinal canal, which requires more attention.
For adhesions caused by distant causes, mechanical obstruction is mostly incomplete, the position of the intestinal canal is relatively fixed, and sudden aggravation leading to complete obstruction is less likely, mostly due to obstruction of intestinal contents. It is better to abandon further surgery and close the abdomen. After surgery, total intravenous nutrition and abdominal heat therapy can be given, and most of them can be cured.
If surgical solution is necessary, the following sequence can be followed, which hopefully will reduce the risk of surgery.
First, the colon is first separated along the peritoneum in all directions, freeing it to reveal the colon and using this as a boundary to avoid colon injury as much as possible. (In this case, enterostomy is difficult to achieve, and every effort should be made to avoid a situation in which it is necessary to create a fistula.)
Second, first do not rush to start separating the intestine from the slightly loose adhesions, you should first find out the beginning of the jejunum or/and the end of the ileum, just like unraveling a messy thread, you need to find the thread first, if you pull the loose area first, there seems to be progress locally, but it does not benefit the whole picture!
Third, start separating along the mesentery of the beginning segment of the jejunum and the end of the ileum! Do not take the intestinal canal as the center of separation!
The most critical thing is that the strength of the adhesions is greater than the connection between the intestinal plasma layer and the mucosa, and the one-way separation of the inter-intestinal adhesions is very easy to divide into the interstitial space of the intestinal wall, resulting in a large area of the intestinal plasma layer peeling off, resulting in a situation where you want to cut but cannot cut, and you want to stay but cannot stay.
The distance of separation along the mesentery is closer, so it is easy to distinguish the location of the local section of the intestine, and it is easy to plan in advance the scope of the intestine to be resected or preserved, which can avoid unnecessary separation of inter-intestinal adhesions. In the face of dense adhesions, it is easy to enter the subperitoneal space on both sides to separate, and it is also easier to protect the mesenteric vessels in a planned and focused manner.
Fourth, pelvic separation The pelvis is the most serious adhesions and the most complicated part of the intestinal tube location. The entire intestinal mass should be separated along the gap between the intestinal mass and the pelvic peritoneum, and the internal vascular mass should not be entered hastily.
Fifth, after clearing the mesentery and freeing the periphery of the adherent intestinal mass, the entire intestinal mass is placed within the field of view and separated under direct vision. Pay attention to the two ends first, then the middle. Separate the mesentery first and then the intestinal canal.