Small and Large Bowel

Question 1

What is the most common CT finding associated with blunt intestinal injury?

Answer 1

presence of free fluid
Free fluid in the absence of solid organ injury is present in over 80% of patients with blunt intestinal injury

Question 2

What are “bucket handle” injuries

Answer 2

involve avulsion of the bowel mesentery caused by shear force in high-impact blunt trauma. They are commonly missed on initial CT

Question 3

When is selective nonoperative management a reasonable option for patients with gunshot or stab wounds to the abdomen?

Answer 3

-if the patient is stable, the wounds are tangential, and there are no peritoneal signs.
-with a reliable examination may be discharged after 24 hours

Question 4

What alternative diagnostic method can be considered in stable patients with equivocal clinical and radiographic findings?

Answer 4

Diagnostic laparoscopy can be considered in selected stable patients to confidently rule out injury.

Question 5

When can blunt mesenteric hematomas be safely observed in asymptomatic patients?

Answer 5

-if CT findings are negative for bowel compromise, obstruction, or active arterial extravasation
-may present days later with delayed perforation secondary to devascularization.
-require more than 24 hours of observation to rule out the risk of delayed perforation.

Question 6

How should a systematic inspection of the small bowel be conducted during surgery?

Answer 6

identifying the ligament of Treitz proximally and “running the bowel” hand over hand, with an assistant following to identify the ileocecal valve.

Question 7

How should hematomas involving the bowel wall be managed?

Answer 7

always be opened and evaluated for underlying injury, especially in the case of stab wounds.

Question 8

Why should the mesenteric border be carefully inspected during surgery?

Answer 8

often subtle and can be overlooked.

Question 9

What should be assessed in the associated mesentery during surgery?

Answer 9

full-thickness defects, active bleeding, hematomas, and regions of significant devascularization.

Question 10

When does ligating mesenteric vessels increase the risk of subsequent ischemia?

Answer 10

Multiple ligations, proximal ligations, and ligations near the distal terminal ileum increase the risk of ischemia.

Question 11

What should be done in cases of proximal or root mesenteric arterial bleeding?

Answer 11

Precise evaluation for SMA injury is needed, with possible primary repair or revascularization

Question 12

What should be considered if moderate to large-sized mesenteric hematomas are not explored?

Answer 12

Consider a second-look operation to assess intestinal viability

Question 13

How should full-thickness perforations or lacerations (grade II) involving ≤ 50% of the wall circumference without devascularization be repaired?

Answer 13

using full-thickness absorbable sutures, followed by a seromuscular imbricating layer

Question 14

How should perforations or lacerations involving more than 50% of the wall circumference (grade III) be managed?

Answer 14

resection and anastomosis

Question 15

How should grade III injuries involving the proximal jejunum or patients at risk for short bowel syndrome be managed?

Answer 15

repair these injuries primarily if significant luminal narrowing can be avoided

Question 16

How are grade IV and V injuries managed?

Answer 16

Resection and anastomosis

Question 17

When should a hand-sewn anastomosis be considered during bowel surgery?

Answer 17

if there is significant bowel edema, a size mismatch, or friable tissue.

Question 18

How should the colon be inspected during surgery?

Answer 18

Inspection of the colon usually begins at the ileocecal valve and continues to the peritoneal reflection surrounding the intraperitoneal rectum

Question 19

What tool should be used for suspected extraperitoneal rectal injury?

Answer 19

A rigid proctoscope should be utilized

Question 20

How should posterior colonic injuries be evaluated?

Answer 20

white line of Toldt should be excised

Question 21

What should be identified and protected during colonic mobilization?

Answer 21

The ureters

Question 22

How should large bowel wall hematomas and paracolic hematomas be managed?

Answer 22

opened and explored

Question 23

What does air tracking within the omentum, mesenteric planes, or bowel wall suggest, and how should it be managed

Answer 23

possibility of occult perforations, which should be traced and identified

Question 24

Why should high-energy injuries from high-velocity projectiles or blast injuries be approached differently

Answer 24

may leave a zone of nonviable tissue and capillary damage that might not be apparent initially, potentially leading to delayed perforation

Question 25

What is a reasonable management strategy for grade I and II injuries associated with high-energy injuries?

Answer 25

Resection with primary anastomosis

Question 26

How are destructive colon wounds (grades III–V) managed?

Answer 26

Destructive colon wounds require either resection with anastomosis or colostomy

Question 27

When should the decision to perform an ostomy be considered?

Answer 27

presence of significant comorbidities, high blood transfusion requirements, hemodynamic instability, or compromised blood supply

Question 28

How should the abdominal wall be closed in the presence of fecal spillage or colonic contamination

Answer 28

The fascia should be closed primarily, while the skin should be left open or loosely approximated with staples

Question 29

How can the wound be managed postoperatively if the skin is left open or loosely approximated?

Answer 29

The wound can be managed with negative-pressure vacuum-sponge therapy or dressing changes to allow for secondary wound closure