Small Bowel Obstruction Management: Dx and Tx with a Focus on Minimally Invasive Techniques

Welcome to the East Stromacast. Advancing science.

Hello everyone, welcome to another episode of TraumaCast. in the series of robotics for the acute care surgeon. This is Mohamed Bawazir. I'm an assistant professor of surgery at Tufts University School of Medicine. I'm being joined by my co-host Amy Lariccia. I am an acute care surgery fellow at East Carolina University. I am uh so honored to have uh two experts in robotics in acute care surgery, Dr. Andre Pakula. Well thanks for having me. Always fun doing

So I'm Andrea Pakula. I'm the medical director of robotics. California. Trauma acute care surgeon by training, but Pretty much all robotic now and including my entire emergency job. So um yeah happy Thank you for being here. And we also have another expert in minimal invasive and robotics surgery, Dr. Matt Martin. Yeah, hi, Matt Martin here. I'm a trauma acute care surgeon also by training but

About half of my practice now is also bariatric and MIS, including robotics. I'm at Los Angeles General Medical Center, formerly LA County, and the Keck USC School of Medicine. And uh Uh happy to be here with uh with Andrea who uses up all the robot time. I'm just an amateur next to her.

Thank you for being here today. So uh my first question, um you know, in the recent years there's uh an uptrend in the use of uh gastrograph and challenge. I would like to hear from you what do you think about gastrograph and challenge and what are the diagnostic and uh therapeutic roles for gastrograph and challenge and where does it fit into practice? At uh LA General we use it pretty routinely, um, un unless we have a patient who's got a hard contraindication, which is rare.

We will generally decompress them for several hours if they have significant dilation on their CAT scan, give them gastrograph and uh we'll follow it for at least twenty four hours. I I'm not a big believer in trying to make a decision for OR, not like at eight hours, some people advocate. Uh and and I think it's been helpful, especially in a training program where we have a lot of residents and fellows and I think it just it simplifies the the process. But I do think it's important to know

times when you should strictly adhere to it. And then there are other times when even though it has not entered the colon at twenty four hours, you probably should still hold off and wait on operating. But we can get into those specifics maybe later in the conversation. Yeah, I mean I pretty much followed. is part of the the multi-institutional study that went

When we published it, obviously, you know, the patients excluded were the were the malignant obstructive patients. But I agree with Matt. I don't follow the eight hours. open up, you know, and as we know, you know, gastrographen is great for for the diagnostic effects, like we said. So almost every single bowel obstruction patient, unless they're unstable or it's truly, you can tell within an incarcerated obstruction. I also sit on those patients.

Yeah, I I think probably the biggest benefit of it that I see is it lets us initiate removing NG tube and starting diet significantly earlier than we used to. But I think it's great for telling early on who who has opened up.

And we can get them moving along in their process versus, you know, waiting for a couple of days and watching an NG tube output. You know, if the contrast goes right in the colon, pull the N G, start'em on on clears. I I think that's that's a bigger benefit than Maybe determining who needs to go to the OR later on.

kind of mentioned there are some patients that you want to sit on a little bit longer. Can you talk about which patients those are and maybe some other kind of cues that would make you go to the operating room sooner in some other patients? Yeah, so so the big ones in my mind, one is early post op small bowel obstructions. You know, so someone who's within a couple of weeks to, you know, one to two months from some abdominal surgery and they're back with a partial SBO.

and and you know it's gonna be a nightmare going back in there, those are patients I will sit on and and I say, you know, th this is a patient who needs to force me to take him to the OR. And it'll be forty-eight hours, sometimes seventy-two hours, and people will be saying, What what are you doing? And those patients almost always open up. And if they're not gonna open up, they usually tell you that pretty quickly. So that's one patient population. Then just the other one is the very high risk.

patient like like we had one who was we had just last week severe medical comorbidities. serrotic child B slash C with a recurrent partial small bowel obstruction and hadn't passed gastrograph in it twenty four hours and we were being pushed to operate and we just said, just wait this out and

waited it out for forty eight more hours. Patient completely opened up and did fine. When everybody was saying, this there is no way this patient's going to get through this without an operation. There they need to go to the OR. And and I think we dodged a bullet there. I will say On the flip side, right, I agree, you know, abdominal procedure we don't want to go back and

Three weeks typically, if we can avoid it. But if you've done, and you know, with the increasing popularity of robotic surgery. ETEP approach to hernia. jump to hernia, but this is important for bowel obstruction. Is that, you know, there are a lot of different techniques and a lot Repairs. And so if you have an early post-op obstruction after an ETEP approach, and you know that that posterior layer has been closed, that is

early post up posterior disruption. And so those patients should be taken back because you know they may end what you would see you know some sort of signs for an intraparietal hernia but those are a patient that's undergone a minimally invasive operation a laparotomy where you might want to go back sooner to alleviate that. Know progression to strangulation type of thing. But again, that's probably someone that's not going to sit and have a gastrograph and study.

That's great, thank you. So do you think the gastrographine has have any effect on the hospital length of stay and the rate of operative interventions? Personally for me, I think what Matt was alluding to Starting diet sooner and getting NGOs.

I think it's probably helped to shorten the length of stay and it's you know we were all taught right don't what is it don't let the sun set or rise i don't even remember anymore on a vowel obstruction but you know i i think if now that we have the the diagnostic tool and again the tool that allows for some you know, catharsis and and helping with them to open up, I think that it's shortened the length of stay and minimized or at least decreased the number of

Yeah, I think it's definitely decreased length of stay. But but of course, it's also how you use it. Right. And so, you know, data's kind of all over the map. Th there was actually just decent sized study that came out showing the gastrograph and protocol didn't change much in in at least this hospital setting compared to patients that didn't get it.

But that really comes down to how you're using it, I think. So So uh the data isn't, you know, a hundred percent, but I think the prospective studies show it will decrease hospital length of stay. It'll allow for earlier decisions for operative intervention. I don't know if it's had a huge impact on the overall rate or incidence of patients who ultimately need surgery.

Oh so one last question about uh gastrographen. Do your institutions have specific policies or protocols for what intervals to get x rays, or if you're not gonna really make a decision in twenty four hours, do you just wait and get a twelve and a twenty four hour x ray? Our institution does, you know, they do a series of images and then they'll follow it eight hours. Um, while they're down there drinking, they'll take their images and then they'll get one at eight hours later.

Depending on what time of day that is. We always follow up with, you know, K U B in the morning, right? So I guess it depends on there for us, there is somewhat of a protocol with how the radiologists do their initial images, and then we do one at eight hours, which is part of that. I guess you can call it a guideline if you will. But then if let's say at eight hours there's nothing then I'll still just get an additional image that following.

And then again, just following the patient clinically, you know, for whether or not you need to get more. I don't keep getting KUVs on patients. I, you know, we get the one, hopefully see that there's some movement, but even if there isn't into the colon yet. I if if the patient's not progressively getting We'll sit on that paper. Getting filmed. Yeah, we get an eight hour and a twenty four hour. But the operative decision point uh is the twenty four hour X ray.

The the eight hour I think is helpful. One if it passes through with the earlier initiation, but the other part is it's not infrequently that we see we get the eight hour and there's no gastrograph in anywhere. And and either the patient vomited it all up or somebody put the NG tube immediately back to suction. and suction it all out and and there it's helpful because we'll administer another dose of gastrograppen rather than get a 24 hour that also shows no gastrographin in the patient.

Okay, so let's say you admitted a patient with an adhesive small bowel obstruction. And uh you do the uh eight hours and the twelve hours and still uh the contrast did not go through. How long do you wait before you decide about going back to the OR? Do you wait forty eight hours? Seventy two hours. The Dr. Martin mentioned a few numbers here. So I'd like to hear from you. Is there a rule that you go by or it it's a patient dependence?

Well, it it's always patient dependent. So I'll s I'll just say the patient who's not uh high risk for some reason. We think it's an adhesive SBO. They're not an early post op SBO. They're not a medical disaster. Like I said, our twenty-four hour X-ray is usually our decision point. So if it has not passed into the colon in that patient population, that's usually where where we'll take them to the OR or we'll at least suggest that they go to the OR.

Now, you know, at handing them off to another partner who might want to watch them longer and that's fine. But but I'd say we use the 24 hour as our usual decision point for do they need to go to the OR or now? Yeah, and I think Matt, don't you think I mean for adhesive small vowel obstruction

Within that twenty and that's why I think most people use that twenty-four hour mark is those patients, if they're gonna open up, they're going to open up, right? I mean, unlike the patient you were describing where it was, you know, days and days. I mean, if it's adhesions with the majority will open up without intervention, operative intervention.

I think twenty four hours is a good mark because if it goes beyond that, then you they're probably just not you know they're declaring With worsening pain or distension or not, because they have an easy one.

Yeah, and and I'll just add it, I think the trend, at least for me, has also been much more liberal about pulling the trigger at 24 hours because I try to approach most of these minimally invasive. It's not like I'm doing a laparotomy on everybody. If I was, I would probably be more conservative and maybe wait them out longer.

You know, you have a patient that you decide to take to the operating room. They haven't opened up with a gastrographon. What makes you decide robotic versus laparoscopic approaches for those patients? What I always say or teach or speak to is that First of all, as we know, robotic assisted right surgery is laparoscopic surgery. It's just with a with a different, you know, more evolved tool. But so we always start laparoscopic.

But it's a lot easier to start lap and have the robot available and ready so that you can dock if you need to. If it's beyond just like, oh, it's right there and I'm gonna snip a band and we're done.

ver and it allows you you know to do your exploration versus not having the robot available starting laparoscopically getting in there and it being an extensive adhesiolysis with or without a bowel obstruction and not having that tool available So for me, 100%, I'm planning a robotic-assisted diagnostic laparos. So the robot is available and whatever I need to do from there, you know, I'll and there were times when I don't necessarily need to dock, but I want to have that robot available.

gonna roll things in and it's gonna be, you know, a robotic. Not for us it doesn't happen. That's my Yeah, for us the the biggest factor is robot availability. Yeah. If it's during the day, almost always we have two robots at LA General. They're they're usually in use. we're we're starting to get weekend availability and hopefully night availability. So so we'll we'll use it more then. So I just say I I have I have less availability compared to Andrea. So

In that case, we'll just start it laparoscopically. But if we have the robot available, that's great to have that tool. But are you doing these cases with residents or fellows, Andrea, or are you doing those with just you and a PA or a tech? It's me and a tech. Yeah, we don't have residents. I get residents that rotate through, but they're not. Because they're So it's myself and a tech. No mid-levels, no PAs or NPs or RNFAs.

So I just would like to stress on one point. So the literature that supported minimal invasive surgery for the adhesive small bowel obstruction Slash laparoscopic surgery is mainly for those patients who have a single adhesive band that you can cut, and the patient is released. my imagination that the robotic approach has expanded this application. So even patients with extensive adhesion can be managed still with minimal invasive and robotic approach. Is that statement accurate?

Yeah, yeah, I I'd agree. So I I'd say I mean the randomized trial, the lasso trial. supported a benefit of laparoscopic versus open. And that wasn't limited to patients with, you know, the single adhesive band you sniff. That was all adhesive comers who who qualified. So I I don't necessarily think it's just the patients, you know, with a single band. The big factor there is gonna depend on your skill set and your patience level.

If you have to do extensive adhesiolysis laparoscopically and you know, who who are you doing it with? Uh is it you? What kind of help do you have with the traction? Do you have the robot? Do you not have the robot? I think probably the biggest factor in one determining if this is even feasible though is the degree of bowel dilation. Because if if you have one of those patients who has diffuse significant small bowel dilation, abdomens distended.

Those are very hard to get any kind of working window. So you can look at the CAT scan and you can tell, okay, that th this person's probably not even a candidate for trying this laparoscopically or robotically. Fortunately most patients are not in that category and they they can readily have this done with an MIS approach.

All right, so let's talk about the technique. I would like to talk about gaining access in patients who have distended bowel. What is your optimal approach to gain access into the abdomen? Uh varus needle, optiview, open technique. I would like to hear from you. What what you do and learn from you? First of all These patients all get a Right ahead of time. So the CAT scan kind of mentioned is very helpful in giving some sort of an idea as where the pathology might be.

First, I use that as a guide if it's obvious that there's a transition point, you know, in the pelvis. in the upper abdomen if it's in the right upper quadrant then I'll be starting you somewhere on the left but if Whether I know or not, typically I enter somewhere around Palmer.

I am an optical entry for everything. That is what I'm comfortable with. And, you know, I think entry into the abdominal cavity is just based on comfort and what you're comfortable with and getting in safely. I don't think there's a right way or But for me it's optical and that's anywhere. And then based on that, as I take a look around, if you can generally figure out where the pathology is. And you know, with even with very dilated bowel manipulating the patient.

To have a laparoscopic grasper to try to move things around, and then based on what I'm able to find, I'll place my additional ports to be able to target appropriate. But having said that, you know, if you're wrong and it happens occasionally Then placing one or two extra ports Change the orientation as to where you're working. I don't, you know, I don't think any patient is going to be upset with five incisions or six incisions.

compared to a laparotomy. Not that they're going to be upset, right? We're helping them, but point being, if you are wrong and where you think you are the pathology Or you need that to be able to be in multiple quadrants or different areas, I think that's So Andrea, so you mean you mean optical entry without prior insuflation? Correct. Yes. I don't varys and then optically enter. I I optically enter.

Okay. Yeah, yeah. And I I do exactly the same thing. I I j I can't stand the Verus. Drives me crazy. You can do a very safe optical entry. And just just like Andrea said, you look at the CAT scan where the most dilation is, you you can also see where your best window is probably gonna be. But then the other big factor too is what is their prior surgery and where are their incisions.

So, you know, if if they've had uh pelvic surgery, have a phanage steel, I'm going upper abdomen. If they've had a big upper midline, then I might actually be opting into one of the lower quadrants. So I'd also base it off their prior surgery and their incision.

talked a little bit about, you know, port placement and patient positioning, but you talked a little bit more about Placing the patient supine versus maybe if you're gonna put them in like a lithotomy position when I know probably based on the CAT scan helps you make that decision, but any other points that you would make to help position the patient. Give you the best chance of staying laparoscopic.

Yeah, for me for specific to small bowel obstruction, I don't put patients in lithotomy unless I think I'm gonna be doing a left cold. So small bowel, personally, they're supine. With respect to port placement, there's a couple of different configurations you can do. And one of the things, and mind you, I'm going to speak mostly from the robotic side, right? I'm not going to talk laparoscopic. Since that was the question or the topic, but

You can run the entire bowel from a left lateral approach. And it's actually what we do more now than what we were previously doing, which is a horizontal port configuration, kind of across the midline, where you would double dot. So you would start in the upper abdomen and then you'd undock, you'd rotate the boom and then you'd go down.

That can get tricky because you need to either have an assist port or be prepared and think about marking your bowel proximal and distal because when you undock you know how easy it can be to lose the bowel even laparoscopically you're holding on to two limbs and you're like what's proximal what's

So there's a couple of tricks to manage that, but actually now going through a left later for me typically obviously like Matt said, if there's previous scars and you're not going to enter on the left, maybe you want to go on the right, clear adhesions. but i do the majority through a left lateral approach and you can run the entire bowel valve Yeah, I I agree. I think left lateral is is the way to go.

I will always tuck the left arm, especially if we're going to be laparoscopic, because even if you think you're going to be oriented towards the head and then you see it's in the pelvis and you're going to have two people on that side, it really gets in your way if you forgot about that and have the arm out.

So I've tuck that arm at least to the side you're gonna be working on. And I never do lithotomy for small bowel, same as Andrea only if I thought I was gonna be doing something with distal colon.

Excellent, thank you. So um what is your preferred technique and instruments that you use? There's different techniques for adhesives. There's the blunt and scissors, monopolar scissors. and the vessel sealer. So uh which technique would you use and what type of adhesions that use that specific instrument? Yeah, so laparoscopic we have a a set of blunt bowel graspers and some places call them bananas or waves.

I always make sure I have at least three of those on the set, because almost invariably there will be one on the set, and then there will be multiple graspers that are designed to tear bowel in half. So you gotta make sure you have the set with at least three uh at traumatic bowel graspers. So I'll I'll start with two of those and usually a monopolar shears. I I don't do bowel lysis of adhesions with a ligature or a harmonic.

You know, I'll I'll use those for like taking down momentum or something off the abdominal wall, but uh I don't think those are uh appropriate for doing uh fine adhesiolysis, especially between bowel loops. How about you, Andrea? Yeah, for laparoscopic I c totally agree in that yeah, bowel graspers and For robotics. I'm pretty standardized in what I use for the majority of type

So any bowel case for me, I always have a fenestrated bipolar. Um, and I'll talk about I'll talk a little bit about instruments because I get this question a lot about how what you can hand what instruments. bowel. So fenestrated bipolar.

and a tip-up grasper which is the curved bigger tip up because with bowel especially in patients with bowel obstruction you want to minimize the grasping of the of the bowel that will help to minimize ileas so it's a lot of sweeping And so my adhesiolysis I do with the monopolar scissors because most of that is going to be sharp, some blunt sweeping away.

Minimal cautery. If it's adhesive bands or omental adhesions, then yes, I'll bring out the vessel sealer for that because that'll obviously take, you know, thicker tissue and bigger vessels. But the majority of adhesiolysis.

And then you can handle the bowel with a fenestrated. I like having the fenestrated bipolar just in case you get, you know, a little mesenteric bleed or something else bleeds, because I prefer to handle You can grasp the bowel with fenestrated bipolar or the Cautier, which is a less

Grip strength. If I'm reducing bowel though, let's say we have adhesions, and that's because of a you know midline incisional hernia and there's the cadet or less grip, you know, uh an instrument with less grip strength that's more for bowel hand. But that's typically the instruments.

Yeah, and and I'm always doing these cases with trainees too. So that's one reason I love especially the tip up. It is great for grasping bowel. It will be very hard for them to tear a bowel in half with it'cause usually it'll slip off rather than than tear the bowel in half. So I mean that's another factor you really gotta consider, especially In a case with small bowel handling with the robot. It is very easy for someone who's not experienced with visual.

control haptics and not getting any manual haptic feedback to put holes in the bow. So so that's something else you have to have in your mind if you're gonna be doing these with trainees and especially junior trainees who don't have a lot of robotic experience. that that don't have uh D V five access. Yeah. Or they don't have a D V five, which is most of most of the country property. Yeah.

Yeah, I'm glad you brought that up. It was gonna be one of my questions about, you know, when you do robotic license of adhesions and m handling the bowel robotically, some of those other cues people can look for that maybe you're having too much tension. You're asking what are the cues to look for? Yeah, are there other cues to look for when you feel like there's too much tension on the bowel?

One of the first things that is really important to learn with robotics, whether it's small bowel or gallbladder or anything, is Understanding that tissue tension, right? What that looks like. And that is truly a learned visual, you know, cue, I guess. You can feel as that visual. it stronger, you start to feel what you're doing, but it's different than, for example, I, you know, I I alluded to force feedback on DV5, which gives us that feeling.

So that it's it's completely different because that's their way of giving us some quote haptic, you know, senses now. But I think it's just a matter of understanding what the bowel, for example, is doing as you pull. Same with even laparoscopy, even though we have that ability to have that.

feedback or that haptics, you can tell if you're going to tear something. So I think you just have to be pay close attention to the tissue and what it's doing, but also just know how to handle the instruments. If I'm running or pulling on bowel, I'm not pulling right because you will inevitably tear it because you don't have that true sense of of of haptics that we do

I don't know. Matt Matt, do you have a a different or I guess better way of explaining it with what the actual cues are that you look? Yeah, no, I agree. And Just happens that there's a journal of trauma article and video by Martin and Pacula. on minimally invasive techniques for uh emergent small bowel pathology. And uh I just I put it in the chat. Maybe you can put the link when you post this for anybody who wants to go watch it. But it goes over

some of these tips about bowel handling in small bowel obstruction cases. But but I so one is that visual haptics that Andrea was just talking about, which that that just takes time to develop. And and then there's just other principles and again if you're doing this with trainees, you really gotta harp on them about it. And one is handing off the bow. So if you know if if

they're running it and then I grab it, they need to let go. You don't want to have each of you grabbing it and pull it in opposite directions. So it's handing it off hand to hand. Uh if the bow is really dilated. I will grab the mesentery. to run it rather than grabbing the bow. I'd much rather have a tear in the mesentery than put a hole in the bow.

And then the other one is just like a vein where you don't wanna take a small grab of a vein. If you're gonna grab a vein, you wanna take a big grab. You wanna take a big grab of the bowel. And not take a real small grab, because that's also how you're you'll tear a hole in the valve when it's dilated and inflamed.

Well that's great. Thank you for sharing the link. I'm gonna put it in the show info uh when we publish this. Thank you. So one last question about the techniques and then we're gonna move on to the cases.

What would be your indication to convert to open? what would be the threshold like at some point like this is not doable, I'm gonna convert to an open procedure. For me, I would say on the cases that I've had to convert, usually the reason is because the bowel is so tensely dilated, diffusely intensely dilated, that

It's like a what do you call it? A bent inner tube, right? You just or uh well, we'll just say a bent inner tube in the sense that it's very difficult to run and to maintain your For me, it's if I can't fully visualize because if it's adhesive disease and it's not a single adhesive band and I'm unsure maybe it's even an internal hernia, I I remember the last bowel obstruction that I actually Internal hernia. Deep at the base of the mesentery.

And I could identify where it was, but the bowel was so dilated, I couldn't, I could not get it reduced. And I didn't feel that I was going to be able to get it reduced and see everything and not injure. And after struggling and going, you know, I'm flipping it around, I knew exactly where it was, which was frustrating because it's like it's right here, but I just could not see.

completely reduce it and feel good about, you know, the reduction and and the correction of the problem. So that that's probably the biggest thing for me is if I just truly can't run the ball. In my mind, there's really only two main indications to convert to open. One is you can't establish an initial window.

to start working. And and you'll have that occasionally patients who have had multiple prior abdominal surgeries and you put a trochar in and either you can't get a space or you insufflate this little space and you just see wall to wall adhesions and bowel fuse the abdominal wall. So that's one. And then the other is just failure to progress. It's not extensive adhesions. It's not, you know, severe disease, because even if you have that, as long as you're progressing.

I'll I'll spend a couple extra hours doing this than I would have done

open as long as we're progressing. But if we get to the point where we're not progressing, uh, or, you know, we've we've caused uh an iatrogenic injury, you know, tore the bow and it's spilling. Uh but other than that, um I'm pretty persistent and I know uh Andrea certainly is pretty persistent as as long as you're making progress, that there's just such a benefit of avoiding a laparotomy in a lot of these patients that it's worth it.

All right. Thank you. That's great. So now we're gonna move on. I have a few cases for you.

They're definitely challenging ones, but I would like to see what you you think about DC. So um the first one is a um sixty years old who had a remote Gastosinostomy for an SMA syndrome. It was done 15 years ago. But he is in clinic now. He has multiple episodes of small bowel obstruction and with repeated visits to the ED, and they're all resolved spontaneously with gastrograph and challenge after 24, 14.

And the the patient is saying that I cannot live like this. I would like something to be done. How would you evaluate these patients? Is there a rule for CT interrography before going to the OR? And I would like to hear from you what you what you do. Funny because I have a patient right now, although it's not with previous GJ, but he has had previous surgery. It was exactly how he's presented to me in the office. He has had multiple obstruction

obstructions, all have resolved with gastrographine, but he's had three within, you know, within the last year and he's beyond frustrated and wants me to do something. So I've I've gotten imaging, I've gotten recent imaging. see mostly just to see if I can identify and compare it to all of his past images. The area of problem we'll say is in the same spot in every image, which is helpful, right? Because you know there's a problem, even though it and this is going to be adhesive disease.

And I I had a very long conversation with him and I told him, I said, you know, as we all know, surgery leads to more adhesions. I can go in there and lice some adhesions, but it doesn't mean that you're never going to have another ballad. I also told him that there's no guarantee I can do it robotically, right? Because d depending on the extent of whatever his adhesions are from his previous surgery. So

For me, it it it takes a lot for me to take somebody with this type of a presentation, but the patients are miserable. And as long as they understand that, you know, there's no guarantee, obviously we document that well, but I'm gonna do my best. p area of of problem then I you know I I will do I'll do what I

I also then say, do you want me to open you? Because I don't think that it's worth going through and an opening you when you haven't required a resection from this. He's actually had a resection from previous obstructions. But, you know, he's he's gotten to the point where he hasn't needed a resection. He's gotten through with gastrographine. I don't want to over That's my my kind of thought on it. I don't know, Matt. What uh what do you think about those are tough?

Yeah. So, and I guess this patient you're talking about specifically, I guess first question would be why'd they do the wrong operation for the SMA syndrome? I was wondering that too, but Should should have been a duodenoginostomy. Yeah. So for this patient specifically, the first couple of things in my mind, one would be establishing this is truly small bowel obstruction.

'Cause there is a significant incidence of just recurrent obstructive symptoms from persistent SMA syndrome or dysmotility of the stomach and the G J. So s but assuming that's not it and this is just true adhesive small bowel obstruction that's recurrent. I think there's a great argument for offering surgery in patients who are having multiple recurrent small bowel obstructions. And there's now some very good data on this.

Like Avery Nathans, they did a huge nation nationwide analysis and just showed you can markedly decrease the incidence of recurrent small bowel obstructions by taking them to the OR versus continuing to do multiple non-operative trials.

So in this patient, if again, I'm convinced this is adhesive small bowel and not, you know, recurrent SMA, I would offer them a laparoscopic exploration, the counseling that There's a risk of us not finding the source and there's a risk of converting to open, but this most likely will decrease the incidence of these recurrent small ballads draft.

Great. Thank you. One more case to kind of go over. So you have a 40-year-old morbidly obese man, BMI of 65, comes in with large hernia with incarcerated small bowel and some colon. You've tried to treat him conservatively, but he's failed. What is your approach and how do you then kind of address that large hernia defect? His is about 13 centimeters. What kind of hernia? Ventral hernia. Uh incisional or primary?

Uh primary. Started out as a small umbilical hernia and then it's just grown with the patient over the years. Okay. Yeah. So again, in in my mind, we actually see this a lot. of these patients come in obstructed with a ventral hernia, but you know, they're not a they're not an ideal operative candidate, high BMI and

People will try to limp them along and and the they'll relieve the obstructive symptoms. They'll send them home. They're back in the ER the next week and y you just gotta bite the bullet and when they start having small bowel obstructions in a hernia, you you just you gotta do something with it. Obviously in the acute setting, that's not the time to be doing some kind of complex abdominal wall reconstruction. So for me, this patient would be a robotic approach.

BMI of sixty five, your patient will love you and your spine will love you compared to doing these laparoscopically. And I would reduce reduce the small bow and ensure I had the site of obstruction and it wasn't something other than the hernia. And then most likely I would probably just do a quick IPOM, get out, and you know.

see if they do fine with that and sometimes that will hold them or if they have a recurrent hernia, then, you know, do a a better procedure electively. Hopefully after they've gotten bariatric surgery and gotten their BMI down. Yeah, I mean you know The problem with there's a couple things with this, right? First of all, it's a 13 centimeter defect. You're not going to get that closed primarily. So an IPOM is going to be an IPOM bridge. They will recur, right? Because all we're doing is

Hopefully a potential reincarceration. But a 13 centimeter defect is large. So most likely, if this is primary, you said primary. Yeah, if this is a primary ventral, then, you know, there's going to be some adhesions within that defect. I would probably just relieve or alleviate the obstruction due to adhesiolysis, and I may not do anything with that.

um depending on what it looks like because yeah for sure a bmi of 65 we're not doing a definitive that patient probably needs posterior component separation and that patient an emergency problem, which is the bowel obstruction, which we need to deal with, deal with the hernia after they're optimized and ready for that. And maybe it's one of those kind of um I've seen these before, they come in, they're obstructed and they have dead bowel within a kind of a lobulated or multiloculated ventral.

And you know that they're probably gonna reincarcerate, then I totally agree. If you can't primarily close and you can just bridge that defect. Let them get through the emergency hospitalization and then work towards getting them optimized.

What if the hernia is an incisional hernia and not a midline hernia? Let's say, for example, it's a previous appendectomy scar, and the patient has a 13-centimeter hernia defect. And they're coming with this small bowel obstruction. So it's incisional, not Medline hernia. Would you do anything differently? Is there BMI still sixty five? No, this patient is much lighter. Um okay, well for the lighter patient.

you know, uh appendectomy similar to a spagalion, right? Those often present with obstructions. So if there's no in my mind, if I have a patient that comes in that's pretty well optimized, we'll say, even though it's They have no need for a bowel resection, there's no bowel compromise, and you can do a nice extra peritoneal repair and closure of the defect and place mesh. Then I don't mind, and I we do this with inguinals, we've done it with you know, I do it with spaghetti.

Kind of like what you're saying. A BMI 65 is a whole nother beast, right? So that's a whole nother thing. But for the otherwise healthy ish or better options. I would treat a a lower incisional similar to an inguinal in the sense that if I can reduce the bowel, they don't need to be resected. And the the defect will come together with closing it, you know, primarily and then placing an extra peritoneal mesh, then that's probably. I absolutely agree. I would I would approach that similarly.

It's it'd be relatively uncommon you'd have that big of a defect from a a prior appendectomy, but sometimes you do. But I I think if you can get a a nice extra peritoneal repair, if you can get the defect closed primarily and normal BMI patient. That would be that would be ideal. Uh I think it would also depend, you know, again, if this is someone who's got diffusely dilated small bow and they're they're pretty distended, you're probably not going to be able to to get that closed.

But if it's, you know, the the usual the bowel's not too distended, then that would be perfectly reasonable. I actually let me ask you a quick question, Andre. So what are you closing that defect with? Because I'm assuming you're using barbed. Are you using the the non-absorbable barbed or are you using the absorbable barbed?

So for my lateral defects, I would use an abs absorbable O. I use number one non-absorbable for midlines, either my tars or eTeps where I'm placating a big diastasis. Everything else.

All right, uh one more case. This is a 65-year-old female. She had a history of remote open colysis techniques. She's presenting with acute abdomen. Clinically she's slightly tender in the right upper quadrant. The seat scan showed that stomach and the proximal small bowel are collapsed, but there is a a loop of small bowel that seems to be distended in the ratipo quadrant, and the radiologist is calling a closed loop of Her watzel count is fourteen thousand. How would you treat this patient?

Sorry, did you say that there's an incisional hernia or not? I didn' No no honey this time. Oh okay. So this is just a clo A closed loop obstruction in the right upper corner. But a prior open call. Correct. That was the that was the fake out. I was assuming it was a open coley incisional her. That's what I was that's what I was thinking. I I I mean, why count a 14,000 closed loop? You know, I probably take her and Take a look at the yeah.

Yeah. Yeah, same here. I'd put a scope in. Lysy adhesions. Yeah, I mean you said she has an acute abdomen if it's a closed loop. I I wouldn't sit on that. And then just determine interoperatively. Is this a license only? Yeah, so... Do I do I need to do a small bower section? So there is a a closed loop obstruction. The bowel is um

kind of idymitous and dusky looking that closed loop. So you did the adhesiolysis, but the bowel is still dilated and uh like uh after the adhesiolysis the bowel look Unhealthy, damaged. So I'd ask anesthesia to give ICG. I'd evaluate the, you know, the perfusion with ICG. And based on You know, in obvious For the most part, I I I I will say I do trust ICG with bowels. So if it perfuses well, I'd leave it alone. I wouldn't do anything.

If it's, you know, ischemic and there's areas of concern, then I would just resect it and Um but if the ICG looks good, perfusion looks good, I wouldn't do anything with it and I would closely Yeah, I I do exactly the same. And the only other factor is sometimes, especially if it's kind of a chronic closed loop. you'll you'll have like a fibrotic area. So if there's like a tight stricture of the small bow there, my conic battle needle resection also. But if it lights up on the the firefly

And currently our only option for ICG fluorescence uh angiography is robotic. We don't have it laparoscopic. So it's another reason, at least in my setting right now, to do the robo. But if the bowel looks okay on the the uh fluorescence angiography, then I will leave it alone. I I just had an incarcerated femoral hernia.

Got the bowel reduced. It actually looked pretty bad. I would have hundred percent respected this if I didn't have ICG. Gave ICG though, it it all lit up. It was just pretty bruised and left it in and patient did great. Can I ask one final question? Absolutely. So Andrea, so this this same patient has a incisional hernia from that open colee, uh and this loop of bowel was stuck in there and ischemic and you did have to resect it. And doing anastomosis. What are you doing for the hernia now?

Luckily for the most part, right, this isn't a hundred percent, but if you're getting a Richter's type, you know, of incarcerated or strangulated hernia, that defect's probably So I am resecting, doing the anastomosis and just primarily closing. And you know, I've done this a bunch of times. I won't do any message.

Um, if I'm resecting, and you know, there's there's data to support the use of extraperitoneal mesh, even in the setting of bowel resection without a lot of spillage, but I am still of the mindset that they are presenting for their bowel obstruction. McVowell, not for the hernia.

Even with bioabsorbable and other meshes. So I'd rather give them a diff uh primary closure, resect, anastomose, let them recover. And I always tell them, you know, there's a good chance you'll recur, right? Because it's incisional hernia. Primarily closed and when you do, I'm happy to do a definitive Come back to fight another day, right?

All right, that was great. Thank you so much. That brings us to the end of this trauma cast. Thank you so much for your time and for your contribution to uh this trauma cast. Yeah, thanks for having us. Good discussion. Thank you. Thanks. It's always fun, Matt. That wraps up another episode of Triumph. Brought to you by the Educational Resources. So you don't miss any. If you're searching for the first time. And career development. Look to the east.