Intestinal Obstruction

INTESTINAL OBSTRUCTION

(General Principles )

* Definition: Failure and arrest of distal downwards propagation of

the intestinal contents.

* Classification

I. According to intestinal movements into adynamic and

dynamic obstruction.

II.According to level:

1. High small intestinal obstruction: affect duodenum or

jejunum.

2. Low small intestinal obstruction: affect ileum.

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Intestinal Obstruction

3. Large intestinal obstruction.

III. According to pathological nature:

1. Simple mechanical obstruction : obstruction of a gut by an

organic cause without interference of its blood supply.

2. Strangulation: impairment of blood supply of the affected

bowel segment occurs. If strangulation is not relieved within 6
hours → gangrene occurs .

3. Paralytie ileus: Loss of intestinal peristalsis & tone → loss of

propulsive power of the bowel → functional obstruction.

IV. Clinical Classification:

1. Acute obstruction:

• It has rapid onset , symptoms are early and usually affect small
intestine.

2. Chronic obstruction:

• It has gradual onset , symptoms are incicious and usually

affect large intestine. There is progressive constipation,
distension & abdominal colics.

3. Acute obstruction on top of chronic: A narrow lumen in

chronic intestinal obstruction become completely obstructed by
impaction of hard faeces.

*Aetiology:

A. Adynamic obstruction: Paralysis of intestinal movements as in:

1. Paralytic ileus. 2. Acute mesenteric vascular occlusion.

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Intestinal Obstruction

B. Mechanical (Dynamic) obstruction: the intestinal movement

intact but there is a mechanical factor which causes obstruction.
The obstructing factor may be:

1. In the lumen: F.B., hard faeces, gall stone ileus & mass of
parasites.

2. In the wall:

a. Congenital: Congenital atresia or stenosis of duodenum,

jejunum or ileum, volvulus neonatorum , imperforate anus,
megacolon, microcolon and meconium ileus.

b. Stricture of intestine: postoperative, T.B., ulcerative colitis or

Crohn’s disease.

c. Neoplasms: Colorectal carcinoma is the commonest cause of

large intestinal obstruction .

d. Volvulus and intussusception.

3. From outside:

a. Adhesive obstruction is the commonest cause for small

intestinal obstruction in adults .

b. Obstructed and strangulated hernia is the commonest

cause for small intestinal obstruction in children .

c. Compression or infilteration of intestine by any abdominal

neoplasms.

*Common aetiology according to age:

• Strangulated hernia is the common in any age.

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Intestinal Obstruction

1. Neonates: Atresia or stenosis of intestine (duodenum, jejunum or

ileum), volvulus neonatorum, meconium ileus, imperforate anus &
congenital megacolon.

2. Infants: Intussusception , congenital megacolon & strangulated

hernia .

3. Children : Strangulated hernia is the commonest cause .

4. Adult : Adhesions are the commonest followed by strangulated

hernia which the second common .

5. Elderly : Adhesive obstruction , strangulated hernia , colo-rectal

carcinoma , volvulus of sigmoid colon, , paralytic ileus, gall stone
ileus and mesenteric vascular occlusion.

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Intestinal Obstruction

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Intestinal Obstruction

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Intestinal Obstruction

Vovulus Neonatorum

Congenital megacolon

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Intestinal Obstruction

*Pathology: 4 pathological types:

1. Simple occlusion:

• The intestine distal to the obstruction show normal peristalsis

and absorption → empty intestine become immobile and
contracted → absolute constipation.

• The intestine proximal to the obstruction :

▪ Hyperperistalsis to overcome the obstruction → colics

▪ Powerful antiperistalsis → vomiting.

• If the obstruction persists → the gut becomes flaccid → stasis of

the contents → infection → severe distension with:

▪ Gases : swallowed air (70%) , diffusion from congested vessels

in the intestinal wall ( 20%) & bacterial fermentation (10%) .

▪ Fluids : GIT secretion ( 8 liters ) and diffusion from congested

vessels in the intestinal wall .

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Intestinal Obstruction

2. Strangulation:

• Due to high in the lumen of the gut → Pressure on the wall of the
gut → occlusion of veins in the wall of the gut → transudation of
massive fluid in the lumen → more pressure on the wall of the gut
→ occlusion of arteries in the wall of the gut → moist septic
gangrene of the gut → perforation → peritonitis.

• Mucosa of gut is the first layer affected by ischaemia → acute

ulceration & intra-luminal haemorrhage .

• Bacteria & toxins migrate through the devitalized wall → peritonitis

, septic & toxic shock .

3.Closed. loop obstruction: Typical form is seen in volvulus.

4.Neurogenic obstruction: The commonest form is paralytic ileus.

*Complications:

1. Shock: May be neurogenic from pain, hypovolaemic, toxic or

septic.

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Intestinal Obstruction

2. Fluid and electrolytes imbalance due to vomiting →

hypovolaemic shock.

3. Toxic absorption from the retained fluid → toxic shock.

4. Strangulation → Perforation → peritonitis → septic shock.

5. Respiratory complications.

*Diagnosis of acute intestinal obstruction :

I. Is there Acut I.0: (C/P & investigation)

A. Symptoms:

1. Abdominal Pain: (earliest presentation)

• Present in all cases except paralytic ileus.

• Pain is colicky (hyperperistalsis) and intermittent .

2. Vomiting:

• It is persistent and projectile (except paralytic ileus).

• Early in high small intestinal obstruction and late or abscent

in large intestinal obstruction .

• First clear, then bile stained and finally black offensive

(faeculent, not fecal vomiting).

3. Absolute constipation:

• There is failure to pass faces & flatus.

• It is early symptom in large intestinal obstruction and late in

high small intestinal obstruction .

4. Abdominal distension: occurs in advanced cases.

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Intestinal Obstruction

B. Signs:

1. General examination: Manifestations of shock (mention) and

dehydration.

2. Abdominal examination:

a. Inspection: may show distension, hernia, visible peristalsis

(site and direction) and borborygmi (mechanical
obstruction), operative scar suggest adhesive obstruction ,
swelling (tumour).

b. Palpation: may show

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Intestinal Obstruction

1) Strangulated hernia (tense, tender with no impulse on

cough).

2) Abdominal mass (tumour or intussusception).

3) Tenderness, rebound tenderness, rigidity & gaurdening

over the affected loop, if strangulation occur.

c. Auscultation: may show

1) Loud exaggerated intestinal sounds in mechanical

obstruction.

2) Dead silent abdomen in adynamic intestinal obstruction.

d. P-R examination: May show the cause of obstruction e.g.

cancer rectum or faecal impaction.

C. Picture of complications: (mention in short).

D. Investigations:

❖ Aim :Confirm diagnosis of intestinal obstruction , diagnosis of

cause & level of obstruction and to estimate the severity of
fluid & electrolyte imbalance .

1-Blood picture : Leukocytosis indicates strangulation.

2-Blood urea and electrolytes : show acidosis, hypokalaemia,

hyponatraemia, rises of haematocrite.

3- Ryle’s tube and suction: brings a large amount of fluid. In

simple occlusion aspiration → partial release of pain while in
strangulation no effect.

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Intestinal Obstruction

4-Plain X-ray :

• In the erect position: mutliple fluid level in a dilated loops

confirm the diagnosis .

• In supine position: The level of obstruction is diagnosed

by dilated proximal loops which give characteristic gas
shadow as follow:

▪ Jejunum loops are central with characterised by

valvulae conniventes & concertina appearance crossing
from one side of the lumen to the other .

▪ Ileum loops are central and appear as structureless

tubes.

▪ Colon is peripheral and shows haustrations ( do not

reach the other side of the lumen ) and sacculations.

Erect position Supine position (Jejunum loops)

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Intestinal Obstruction

Supine position ( Colon ) Supine position (Ileal

loops)

5- Barium enema: to detect any colonic obstruction.

6- Ultrasound may show distended loops or mass of

intussusception or tumour.

7- CT scan with contrast is 90% sensitive in the diagnosis

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Intestinal Obstruction

II.Diagnosis of level of obstruction :

High small Low small Large

intestine intestine intestine
1- Pain ▪ Above umbilicus ▪ Below umbilicus ▪ Peripheral
& right iliac fossa
2- Vomiting ▪ Very early ▪ After about 12 ▪ Late after few
hours days.
3- Distension ▪ Minimal, central ▪ Moderate, central ▪ Huge & peripheral
in the flanks .
4- Absolute ▪ Late ▪ After few hours ▪ Early
constipation
5- Shock & ▪ Early & severe ▪ Moderate ▪ Minimal
dehydration

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Intestinal Obstruction

III. Diagnosis of pathological type:

Simple Strangulation Paralytic iteus

occlusion
1- Pain ▪ Colicky, ▪ Sever, persistent ▪ No Pain
intermittent
2- Shock ▪ Minimal & late ▪ Early & severe ▪ Moderate
3- Palpation ▪ -ve ▪ Tenderness, ▪ -ve
rebound tenderness
& rigidity
4- Auscultation ▪ Loud ▪ First exaggerated ▪ Dead silent
exaggerated sound then abdomen
intestinal sounds disappeas
5- Suction ▪ Relieves pain ▪ No effect on pain ▪ Relieve
distension

• Strangulation is also suspected if:

▪ The patient is toxic with high fever, severe tachycardia &

leukocytosis.

▪ Evidence of blood loss as pallor , tachycardia & hypotension .

IV. Diagnosis of the cause:

• Suspected from the age (Mention aetiology according to the

age)

• Characteristic features of the cause eg. strangulated hernia,

adhesive intestinal obstruction , intussusception, volvulus and
paralytic ileus.

*Treatment:

• Rapid preoperative preparation followed by urgent relief of the

obstruction , usually by operation .

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Intestinal Obstruction

I) Preoperative preparation: (Drip & suck)

▪ Method:
1-Rest in bed and sedation.
2-Stop oral feeding.
3-Gastrointesinal suction (most important) by Ryle tube to
decompress the bowel ( prevent strangulation) & to avoid
inhalation & respiratory complications .
4-I.V. fluid ( Ringer’s lactate ) and electrolytes and Blood
transfusion in case of strangulation .
5- Antibiotics to prevent sepsis if there is possibility of
strangulation.
6- Insertion of Foley’s catheter to check the urine output .
7- Observation: pulse, temp., B.P., urine output, amount of
suction , site & severity of pain... etc.

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Intestinal Obstruction

III)Surgical:

▪ Indications :

1- Acute or acute on top of chronic mechanical obstruction.

2- Obstructed hernia or strangulated hernia.

3- Strangulated intestine .

▪ Method:
1) Laparotomy by lower right paramedian incision or incision
over strangulated hernia.

2) Explore the caecum:

▪ Collapsed caecum → small intestinal obstruction.
▪ Distended caecum → large intestinal obstruction.
▪ The junction between the collapsed and distended loops →
site of obstruction.
3) Relieve the cause of obstruction by division of constricting
agent , reduction & repair of hernia, division of adhesive
bands, reduction of intussusception or untwist of volvulus.
4) Viability of intestine is assessed :

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Intestinal Obstruction

Non-viable
 Viable intestine
intestine
1. Peritoneal • Present • Absent
luster
3. Colour • Pink or dark red . • Green, brown or
black
4. Peristalsis & • Present, contract if • Absent & no response
Tone pinched to pinching.
5. Consistency • Firm • Flabby & thin
6. Mesenteric • Present ( most important ) • Absent
pulse(duplex)

5) Management of strangulated intestine as follows:

 If viable: reduce to the abdomen.

 If non-viable small intestine or right colon: resection
with 1ry. anastomosis.
 If non-viable left colon: 3 options.
➢ Exteriorization resection.
➢ Hortmann’s technique.
➢ Proximal colostomy with mucous fistula.

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Intestinal Obstruction

 Doubtful intestine: cover the loops with hot saline packs

changed every 5 minutes for 15 minutes, with positive O2
ventilation then decide whether the intestine is viable or
not.

Exteriorization resection

Hortmann’s technique.

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Intestinal Obstruction

Proximal colostomy
with mucous fistula

III) Certain conservative measures may be successful in certain

situations provided that the case is early & there is no evidence
of strangulation.

1. Ileocaecal intussusception may be reduced by the

hydrostatic effect of a barium enema & the reduction is
radiologically monitored on screen.

2. Sigmoid volvulus: Untwisting of the volvulus may be

attempted using a rectal tube passed through a sigmoidoscope.

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Intestinal Obstruction

3. Adhesive intestinal obstruction may be relieved by I.V drip

& nasogastric suction. If this fails or suspicion of strangulation
are indications for surgery.

4. Faecal impaction is treated by enema to dissolve the hard

faecal mass.

PARALYTIC ILEUS

* Definition: It is a form of adynamic intestinal obstruction in

which there is loss of intestinal peristalsis and tone due to failure of
neuromuscular transmission in the intestine .

* Aetiology:

A. Surgery : Paralytic ileus may occur after any operation especially

after major abdominal or pelvic surgery due to:

1- Pre-operative causes: bad pre-operative preparation (full

stomach).

2- Operative causes: prolonged exposure of intestine and rough

manipulation.

3- Post-operative causes: neglect suction, early oral feeding ,

leaking intestinal anastomosis and peritonitis .

B. Trauma: Fracture spine, femur, pelvis, obstructed labour &

retroperitoneal haemorrhage (may be sympathetic over stimulation ) .

C. Toxic: Direct toxic effect on the intestinal nerve plexuses

may be due to :

1. General: Toxaemia, septicaemia, uraermia, typhoid.

2. Local: Septic peritonitis.

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Intestinal Obstruction

D. Metabolic causes: Hypokalaemia, uraemia & diabetic

ketoacidosis.

E. Drugs : as anticholenergics and tricyclic antidepresents .

* Pathology :

• Normal reflex bowel atony occur following abdominal surgery for

24-48 hours .The duration of postoperative reflex atony depends
on bowel manipulation .

• Usually due to bad post-operative care , a vicious circle of

intestinal distension with gas & fluid  atony of intestine until
complete paralysis of intestine occur .

• In post-operative causes the colon is more affected than small

intestine .

* Clinical picture:
I- History of the cause which is usually following abdominal surgery.
II- Symptoms: usually on the 2nd or 3rd post-operative day.
1. Marked adominal distension is essential feature
2. Absolute constipation: the patient can’t pass faeces or flatus
after the operation.

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Intestinal Obstruction

3. No pain or colic but there is severe abdominal discomfort.

4. Vomiting: effortless & excessive vomitus.

III. Signs: Dead silent abdomen + features of the cause e.g.

peritonitis

* Investigations: Blood electrolytes & X-ray (as before in general).

* Treatment:

A. Prophylaxis: Avoid all the predisposing factors .

B. Curative:

1. Conservative treatment : The main line of treatment and

usually successful .

• Method : Drip and suck ( Mention )

2. In resistant cases give parasympathomimetic drug as

prostigmine.

3. Leaking intestinal anastomosis, necessitate exploration.

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Intestinal Obstruction

INTUSSUSCEPTION

* Definition: Invagination of a segment of the gut into the lumen of a

distal segment of gut.
* Anatomical types:
1. Ileo-caecal intussusception: The commonest , terminal ileum
is invaginated into the caecum with the ileo-caecal valve forming
the apex of intussusceptions .
2. Ileo-ileal: The ileum is invaginated into the distal ileum.
3. Colo-colic: colon is invaginated into the distal colon.
4. Ileo-colic: ileo-ileal intussusception advancing till its apex enters
the colon.
5. Retrograde: as jejunogastric intussusception after gastro-
jejunostomy.
* Clinical types:
1. Infantile type: The commonest, usually ileo-caecal type.
2. Adult type: Rare, due to organic lesion at the apex as polypoid
tumour , Mechel’s diverticulum or submucous haematoma .

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Intestinal Obstruction

* Ileo-Caecal Intussusception*
* Incidence:
• The commonest type, male: Females = 2:1
• Maximum age incidence is 3-12 months ( age of weaning ).
• It is the commonest cause for intestinal obstruction during infancy
• Peak incidence is in summer due to increase incidence of
gastroenteritis .

* Aetiology:
1- Idiopathic but possible adenovirus or gastroenteritis →
enlarged Peyer’s patches in lower end of ileum → stimulation of
hyperperistalsis → intussusception.

2- Other predisposing factors included presence of ileocaecal

peritoneal fold , exaggeration of normal ileocaecal invagination and
abnormal mobility of caecum .

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Intestinal Obstruction

* Pathology:

• The ileo-caecal valve is invaginated into the caecum and in

neglected cases it may travel along the colon and may protrude
through the rectum and anus.

• An intussusception consists of:

1. Intussusceptum: consists of an entering layer and a returning
layer.
2. Intussuscipien: is the outer ensheathing layer.

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Intestinal Obstruction

3. Apex: junction between entering and returning layer (the ileo-

caecal valve).
4. Neck: is the junction between the ensheathing and returning
layer.
• The mesentery containing the blood vessels may be compressed
between the entering and the returning layer → gangrene
(maximally affect the apex).
• Congestion of intussusceptum → rupture of venules and excessive
mucous secretion → red current jelly diarrhea .

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Intestinal Obstruction

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Intestinal Obstruction

* Complications: (as before in general principles).

* Clinical picture:
1. Characterestic incidence (metion it).
2. Attack of colic denoted by the infant crys with flexion of the
thigh and becomes pale. The attacks alternate with intervals of
apparent well being.
3. Vomiting follow the colic in 70% .
4. Abdominal distension is late.
4. Absolute constipation with passage of Red currant jelly
diarrhea (mucous and blood per rectal ).
5. Empty right iliac fossa. (Sign de Dance).
6. Curved sausage shaped mass felt any where around the
umbilicus except right iliac fossa.
7. P-R examination: the apex of intussusception may be felt and
the examining finger is stained with blood & mucous.
8. In late cases, manifestations of strangulation & complications
(mention).

Any infant having coliky abdominal pain with passage of

blood stained mucous per rectum should be suspected to
have intussusception .

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Intestinal Obstruction

* Investigations: (as before in general) +

• In doubtful cases barium enema show :
▪ Claw sign (Cylindrical filling defect with a trace of barium on
either sides followed by sudden arrest of the dye).
▪ Coil spring sign : due to traping of the contrast between layers
of intussusceptions . Claw Sign

Claw sign

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Intestinal Obstruction

* D.D.:

1. Gastroenteritis: There are fever, vomiting, diarrhea, shock is

very late, no mass felt on abdominal or P-R examination.
2. Rectal prolapse: No manifestations
of intestinal obstruction, a finger cannot
pass around the protruding mass.
* Treatment:
A. Hydrostatic reduction:
• Indications : Early cases without any evidence of
strangulation .
• Methods : Barium enema is given under pressure ( which not
exceed 120 cm water) , under radiological control, to reduce
the intussusception.
• Success rate is 85% and is confirmed by free flow of barium
into ileum for more than 5 cm and by rapid clinical
improvement with no further colics .
B. Open or laparoscopic surgical treatment :
• Indication:
1- Failure of hydrostatic reduction.
2- Late complicated cases with evidence of strangulation (
rigidity )
• Methods:
1) Preoperative preparation: Gastric suction , IV fluids &
electrolytes .
2) According to the condition of the intestine (mention features
of viability).

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Intestinal Obstruction

a. Viable intestine → reduction by gentle milking of the

apex in a proximal direction. Complete reduction is
detected by appearance of the appendix.

♣ The proximal ileum should never be pulled

backwards as this may lead to intestinal tears.

b. Gangrenous intestine or irreducibility → resection

anastomosis.

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Intestinal Obstruction

VOLVULUS

⁕ Definition: Twisting of a mobile loop of gut around its mesenteric

axis.

Volvulus of caecum Volvulus of small intestine

Volvulus neonatorum Voluvlous of stomach

* Types:
1. Volvulus of sigmoid colon (the commonest).
2. Volvulus of caecum.
3. Volvulus of small intestine.

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Intestinal Obstruction

4. Volvulus neonatorum.
5. Voluvlous of stomach.

* Volvulus of Sigmoid Colon *

* Predisposing factors:
1. Chronic constipation → overloaded distended colon.
2. Too long sigmoid colon.
3. Narrow attachment of sigmoid mesocolon.
4. Adhesions between the apex of sigmoid colon and anterior
abdominal wall.

* Pathology:

• The upper loop usually falls in front of the lower so that the twist is
almost always in anticlockwise direction → closed loop
obstruction leading to:

1. Huge distension of the sigmoid colon with gas and fluid.

2. The colon above is distended.

3. Rectum below is collapsed and empty.

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Intestinal Obstruction

• Volvulus is a closed loop intestinal obstruction and the main blood

vessels at the base of the involved mesentery is occluded .

• The pressure inside the closed loop rises rapidly with severe
pressure on the wall → strangulation ultimately occur and
perforation follows with rapid fatal peritonitis.

* Complications: “as before in general principles ”

* Clinical picture:
1. More in males above 50 years with chronic constipation.
2. Sudden severe colicky abdominal pain start in left iliac fossa .
3. Abdominal distension soon follows, 1st left sided but later
becomes generalized.
4. Absolute constipation is early but vomiting is absent or very
late.
5. P.R exam.: show empty rectum & blood staining of the finger.

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Intestinal Obstruction

6. In neglected cases → picture of strangulation, peritonitis &

shock (mention).
* Investigations: (As general principles)
1- Plain X ray: distension of sigmoid colon with gas → omega
shaped shadow with its base point to the left iliac fossa .

2- Sigmoidoscopy : diagnostic & therapeutic .

* Treatment:
A. Conservative: For early cases without strangulation.
a. Rectal tube pass through a sigmoidoscope to untwist the
colon → gush of excess flatus & fluid stools.
b. The tube is left in place & the patient is prepared for elective
resection of sigmoid colon to prevent recurrence.

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Intestinal Obstruction

B. Surgical:
• Indications: If there is failure of conservative treatment or
strangulation.
• Method:
1. Resuscitation (Mention) followed by a left lower paramedian
incision.
2. Nonviable bowel : The sigmoid colon is resected , the
proximal end of colon is brought out to the skin as a terminal
colostomy & the distal end is closed by sutures (Hartmann’s
procedure), for later elective anastomosis.

Hartmann’s procedure

3. Viable bowel : sigmoid colon can be fixed to the posterior

abdominal wall or resected as for gangrenous cases to
avoid recurrence.

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Intestinal Obstruction

* STRANGULATION *

* Definition: Interference with the arterial supply of the bowel .

* Aetiology:

1. Simple strangulation: Acute mesenteric vascular occlusion by

acute thrombosis on top of atherosclerosis or embolism → loss of
the propulsive power of its muscle coat.

• Rare, present by sudden severe abdominal pain, bleeding per

rectum, usually diagnosed at laparotomy and highly fatal.

2. Mixed strangulation: Occlusion of arterial supply and the lumen

of the gut as in strangulated hernia, intussusception and volvulus.

* Pathology, complications, Investigations: (as general).

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Intestinal Obstruction

* C/P:

1. Severe shock ( neurogenic , toxic , septic & hypovolaemic ), high

fever , marked tachycardia and the patient is highly toxic .

2. Sudden severe persistant agonizing pain, severe persistant vomiting,

absolute constipation, severe distension,

3. Tenderness, rebound tenderness , rigidity and loss of

movement of abdominal wall with respiration .

* Treatment: Only surgical after rapid preoperative preparation ( drip

& suck ).

1- According to the cause e.g. strangulated hernia, volvulus or

intussusception.

2- In case of mesenteric vascular occlusion:

a. Viable intestine → embolectomy or thrombendarterectomy.

b. Non-viable intestine → resection anastomosis.

ADHESIVE OBSTRUCTION

* Incidence: Intraperitoneal adhesions is the commonest cause of

intestinal obstruction in adults in developed countries.

* Aetiology:

1. Post-operative adhesions :

• The commonest , especialy after appendicectomy or

gynaecological operation.

• Adhesions usually occur at the site of intestinal ischaemia or at

the scar of the abdominal wall .

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Intestinal Obstruction

2. Post- inflammatory adhesions may follow septic or T.B

peritonitis , appendicitis , cholecystitis , Crohn’s disease….etc .

3. Congential: Vitello-intestinal band.

* Pathology:

• Adhesions may be single but usually multiple → bind intestinal

loops to each other or to the abdominal wall → Intestinal
obstruction due to kinking or compressing the intestinal loops .

• Strangulation may result from compression of blood supply or

ischaemic necrosis by direct pressure.

• Adhesions have tendency for recurrence → recurrent intestinal

obstruction.

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Intestinal Obstruction

* Clinical picture:

• History of previous abdominal surgery or inflammation.

• Acute, recurrent acute or rarely chronic small intestinal

obstruction.

• Almost always there is a scar of previous abdominal surgery.

• Features of strangulation may be present.

* Treatment:

I-Conservative treatment :

• Indications: tried in early cases without any evidence of

strangulation , particularly if there is recurrent obstruction.

• Method : Drip & suck .

II- Surgical treatment :

• Indication : if conservative treatment fails with no response for

48 hours or there are evidences of strangulation.

• Method :

▪ Preoperative preparation : drip & suck .

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Intestinal Obstruction

▪ Laparoscopic adhesiolysis may have a role in chronic cases

▪ Open surgery :

➢ Laparotomy is performed .

➢ Obstructing adhesions only are divided , leaving other

adhesions in situ because their division leads to more
adhesions .

➢ To prevent recurrence , any bare area should be covered

by omental graft .

➢ The intestine is examined & dealt with accordingly.

Laparoscopic adhesiolysis

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