1. Dr.Mohammad Amin K Mirza Saudi Board of Surgery Holy Makkah, KSA 2008

2. History & Clinical Data 34 y.o Saudi, female Pt, Married Came to ER c\o: Lt sided abdominal pain, colicky in nature – 1wk Vomiting of gastric content – 1 day No flatus – 3days Passed hard stool – at the night prior to admission H\O open appendectomy 1 yr back ( histopath: acute suppurative appendicitis) No DM or HTN

3. O\E: Conscious, oriented, not toxic, not in destress V.S: Temp: 37 C°, BP: 130/80 mmHg, HR: 96 bpm Abdomen: Mild distension, soft lax no tenderness Bowel sounds: Audible, hernail orifices – intact CBC: normal Chemistry: K – 3.2 Na – 127 AXR: Distended small bowel, multiple fluid levels History & Clinical Data cont..

5. Managemaent NPO NGT D5 ¼ NS 125 ml/hr Inj KCl 60 meq \24 hr Intake output chart

6. Patient progress She showed slow progress Although she had no signs of peritonitis, sepsis, or any systemic response, there was no improvement regarding bowel movement, & she didn’t pass stool or fleatus Correction of electrolytes was achieved on 3ed day of admession

7. Laparoscopic exploration On 5 th laparoscopic exploration was planned as the patient didn’t show any improvement although there was no any signs of systemic response

8. Laparoscopic exploration Dilated small bowel down to Rt colon Severe adhesive process at RIF Release of adhesions done

9. Post-operatively Patient is well & feeling good Weak mobilization No abdominal apin No fever, tachycardia, or hypotention Soft lax abdomen, mild destension NGT 150-200 cc / 24hr AXR – decreased gaseous distension

10. Post-operatively Still didn’t pass stool or flatus No vomiting, NGT – 1050-200 cc greenish K 3.8 Postoperative ileus was considered & decided to start on erythromycin tab 500 mg BD CT scan abdomen was arranged for next day

11. 4 th day post operatively Slow recovery : still no stool or flatus BP: 120/70,, HR: 110, T: 37.4 Patient is well generally, not toxic or destressed Abdomen: Soft lax, mild distension, BS +ve Na 134 K: 3.8 CT abdomen: adhesive process at RIF with obstruction at the ceacum !!!!!!!!!!!!

15. Exploratory laparotomy 2 fibrous bands at the area of Lig. Of Treitz surrounding a segment of proximal ileum It is 20 cm long segment, 60 cm away from ileoceacal junction The segment is thickened adherent to posterior abdominal wall, with small perforation at mesenteric border. Small amount of pus & fibrinous patches in peritoneal cavity Resectio anastomosis done using GIA

20. Post operative course Smooth recovery No fever Oral intake started on 4 th day post op Passed stool on 5 th day Tolerated oral intake Minimal superficial wound infection Pus C/S no growth Discharged in good condition 9 th day post op OPD follow up, clips removed Histopath: acute inflammatory process.

21. Medications Erythromycin Ceftazidime Gentamycin Metronidazole Pantoprazole Enoxiparin

24. Congenital & acquired bands

25. Background Peritoneal adhesions can be defined as abnormal fibrous bands between organs or tissues or both in the abdominal cavity that are normally separated. Adhesions may be acquired or congenital

26. Causes most common cause of is abdomino-pelvic surgery inflammatory conditions Intraperitoneal infection Abdominal trauma Intraperitoneal foreign bodies, including mesh, glove powder, suture material and spilled gallstones.

27. 93% to 100% of patients who undergo transperitoneal surgery will develop postoperative adhesions. Intraabdominal adhesions are the most common cause of SBO accounting for approximately 65% to 75% of cases

28. The risk of SBO is 1% to 10% after appendectomy. 6.4% after open cholecystectomy, 10% to 25% after intestinal surgery 17% to 25% after restorative proctocolectomy

38.  Gastrografin transit time may allow for the selection of appropriate patients for non-operative management.  Some studies have shown when the contrast does not reach the colon after a designated time it indicates complete intestinal obstruction that is unlikely to resolve with conservative treatment.  When the contrast does reach the large bowel, it indicates partial obstruction and patients are likely to respond to conservative treatment.  Although Gastrografin does not cause resolution of small bowel obstruction there is strong evidence that it reduces hospital stay in those not requiring surgery.