Small and Large Bowel Flashcards
What is the most common CT finding associated with blunt intestinal injury?
presence of free fluid
Free fluid in the absence of solid organ injury is present in over 80% of patients with blunt intestinal injury
What are “bucket handle” injuries
involve avulsion of the bowel mesentery caused by shear force in high-impact blunt trauma. They are commonly missed on initial CT
When is selective nonoperative management a reasonable option for patients with gunshot or stab wounds to the abdomen?
-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
What alternative diagnostic method can be considered in stable patients with equivocal clinical and radiographic findings?
Diagnostic laparoscopy can be considered in selected stable patients to confidently rule out injury.
When can blunt mesenteric hematomas be safely observed in asymptomatic patients?
-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.
How should a systematic inspection of the small bowel be conducted during surgery?
identifying the ligament of Treitz proximally and “running the bowel” hand over hand, with an assistant following to identify the ileocecal valve.
How should hematomas involving the bowel wall be managed?
always be opened and evaluated for underlying injury, especially in the case of stab wounds.
Why should the mesenteric border be carefully inspected during surgery?
often subtle and can be overlooked.
What should be assessed in the associated mesentery during surgery?
full-thickness defects, active bleeding, hematomas, and regions of significant devascularization.
When does ligating mesenteric vessels increase the risk of subsequent ischemia?
Multiple ligations, proximal ligations, and ligations near the distal terminal ileum increase the risk of ischemia.
What should be done in cases of proximal or root mesenteric arterial bleeding?
Precise evaluation for SMA injury is needed, with possible primary repair or revascularization
What should be considered if moderate to large-sized mesenteric hematomas are not explored?
Consider a second-look operation to assess intestinal viability
How should full-thickness perforations or lacerations (grade II) involving ≤ 50% of the wall circumference without devascularization be repaired?
using full-thickness absorbable sutures, followed by a seromuscular imbricating layer
How should perforations or lacerations involving more than 50% of the wall circumference (grade III) be managed?
resection and anastomosis
How should grade III injuries involving the proximal jejunum or patients at risk for short bowel syndrome be managed?
repair these injuries primarily if significant luminal narrowing can be avoided
How are grade IV and V injuries managed?
Resection and anastomosis
When should a hand-sewn anastomosis be considered during bowel surgery?
if there is significant bowel edema, a size mismatch, or friable tissue.
How should the colon be inspected during surgery?
Inspection of the colon usually begins at the ileocecal valve and continues to the peritoneal reflection surrounding the intraperitoneal rectum
What tool should be used for suspected extraperitoneal rectal injury?
A rigid proctoscope should be utilized
How should posterior colonic injuries be evaluated?
white line of Toldt should be excised
What should be identified and protected during colonic mobilization?
The ureters
How should large bowel wall hematomas and paracolic hematomas be managed?
opened and explored
What does air tracking within the omentum, mesenteric planes, or bowel wall suggest, and how should it be managed
possibility of occult perforations, which should be traced and identified
Why should high-energy injuries from high-velocity projectiles or blast injuries be approached differently
may leave a zone of nonviable tissue and capillary damage that might not be apparent initially, potentially leading to delayed perforation
What is a reasonable management strategy for grade I and II injuries associated with high-energy injuries?
Resection with primary anastomosis
How are destructive colon wounds (grades III–V) managed?
Destructive colon wounds require either resection with anastomosis or colostomy
When should the decision to perform an ostomy be considered?
presence of significant comorbidities, high blood transfusion requirements, hemodynamic instability, or compromised blood supply
How should the abdominal wall be closed in the presence of fecal spillage or colonic contamination
The fascia should be closed primarily, while the skin should be left open or loosely approximated with staples
How can the wound be managed postoperatively if the skin is left open or loosely approximated?
The wound can be managed with negative-pressure vacuum-sponge therapy or dressing changes to allow for secondary wound closure
