MSC - F. Surgery Answers 2025

13. Treatment of patients with obstructive intestinal obstruction.

Initial Emergency Management

Immediate resuscitation:

o NG/intestinal decompression to prevent aspiration.

o Central venous line → CVP monitoring + fluid resuscitation.

oFoley catheter → hourly urine monitoring (goal ≥ 40 mL/h).

IV fluids:

oIsotonic crystalloids.

oAdd potassium only after diuresis starts.

Antibiotics: Broad-spectrum if strangulation suspected.

Surgery indication: Any sign of strangulation → immediate operation.

14.Principles of conservative and surgical treatment of patients with obstructive intestinal obstruction of tumor origin.

Conservative Treatment (only in early, non-strangulated cases)

Gastric/intestinal aspiration (reduces pressure and decompresses).

Siphon enemas: Useful for sigmoid volvulus, intussusception, colonic block.

Colonoscopy: Sometimes allows decompression or diagnosis.

Time-limited: 2–4 hours. No improvement → surgical intervention.

Supportive therapy includes:

Ringer-Locke, albumin, plasma, amino acids.

Potassium + glucose-insulin for electrolyte correction.

Sodium bicarbonate if acidosis.

Reopolyglukin, trental to improve microcirculation.

Cardiotonics if shock/dysfunction present.

Absolute contraindications to conservative therapy:

Peritonitis

Sepsis/SIRS signs

Multi-organ dysfunction

Surgical Treatment

General Principles

Midline laparotomy

Intra-op decompression: Double-lumen nasojejunal tube for aspiration (insert before Bauhin's valve)

Mesenteric novocaine block: To prevent intra-op shock

Determine site: Dilated loops above, collapsed below

Leave tube post-op for decompression, enterosorbents, antibiotics

Surgical Options (based on cause):

1.Strangulated hernia → Hernioplasty ± resection

2.Adhesions → Adhesiolysis

3.Tumor/necrosis → Segmental resection

4.Volvulus/twisting → Detorsion

5.Bezoar/gallstones → Enterotomy

6.Intussusception → Disinvagination

7.Tumor resection ± stoma (if obstructing)

8.Inoperable tumor → Colostomy or bypass

9.Bypass anastomoses → Above & below lesion Resection margins:

Proximal: 40–60 cmDistal: 10–15 cm

Oncologic Obstruction: Specific Surgical Options

Right colon tumors: One-stage right hemicolectomy with ileotransverse anastomosis.

Left-sided tumors:

oSome centers allow one-stage resection + primary anastomosis in stable patients.

oMore commonly: Twoor three-stage surgeries:

Two-stage: Resection + colostomy → delayed anastomosis

Three-stage: Cecostomy → tumor resection + anastomosis → colostomy closure

Postoperative Management

GI decompression: 3–4 days

Early peristalsis stimulation: Anticholinesterases, prokinetics, electrostimulation

Detox: Adequate hydration, forced diuresis, adsorbents (reopolyglukin)

Prevent DVT: Elastic bandages, anticoagulants, mobilization

Antibiotics: Broad-spectrum IV and intraperitoneal

Abscess: Percutaneous drainage under ultrasound

18.Treatment of patients with strangulated intestinal obstruction.

1.Emergency Surgery is Mandatory

Absolute indication: Confirmed or suspected strangulation.

Delay = death (necrosis → peritonitis → sepsis).

2.Preoperative Resuscitation

NG tube: Decompress GI tract.

IV fluids: Isotonic crystalloids → monitor CVP.

Foley catheter: Track urine output (goal ≥ 40 mL/hr).

Electrolyte correction: Add K after diuresis established.

Broad-spectrum antibiotics: Pre-op coverage (cephalosporin + metronidazole or carbapenem).

3.Conservative Management (Rare)

Only in early, partial, non-strangulated obstructions.

NG suction, enemas, colonoscopy.

Time limit: 2–4 hours. No improvement → surgery.

4.Surgical Treatment

Midline laparotomy

Intra-op decompression: Insert long nasojejunal tube.

Resection if necrotic: Healthy margins (prox: 40–60 cm, dist: 10–15 cm).

Anastomosis vs. stoma: Depends on location, patient stability.

5.Postoperative Care

GI decompression (3–4 days)

Fluid/electrolyte management

Early mobilization, thromboprophylaxis

IV antibiotics (and intraperitoneal via drains if needed)

Abscesses → percutaneous drainage

Key Principle

Strangulation = surgery, not negotiation.

16. Differential diagnosis of obstructive and strangulated intestinal obstruction.

Pathophysiology and Clinical Differentiation:

Strangulated Intestinal Obstruction:

oVascular compromise → venous congestion, edema, cyanosis, progressing to necrosis and perforation.

o Intense, sudden, continuous pain with possible signs of shock.

oRapid systemic intoxication due to bacterial translocation, endotoxins, and tissue breakdown.

oEarly surgery mandatory.

Obturation (Simple) Intestinal Obstruction:

oNo initial vascular compromise; mucosal necrosis occurs later due to pressure and ischemia.

o Pain is more colicky and less severe initially.

oSlower progression allows a window for conservative management if no signs of strangulation.

Imaging:

Plain abdominal X-ray:

o Both show dilated bowel loops proximal to obstruction.

oStrangulation may show pneumatosis intestinalis or free air if perforation.

Contrast studies:

oDelayed transit or retention at obstruction site.

19. Principles of surgical treatment of patients with strangulated intestinal obstruction. Signs of intestinal viability during intraoperative diagnosis. Limits of resection of non-viable intestine.

Principles of Surgical Treatment of Strangulated Intestinal Obstruction:

1.Prompt laparotomy: Median incision to access abdominal cavity urgently.

2.Assessment and decompression: Identify obstruction site; decompress intestine with nasoenteric tube if needed for better visualization.

3.Release strangulation: Untwist volvulus, reduce hernia, or cut adhesions causing obstruction.

4.Resection of non-viable intestine: Remove necrotic bowel segments to prevent sepsis and peritonitis.

5.Restoration of intestinal continuity: Perform anastomosis if conditions allow; otherwise, consider stoma formation.

6.Peritoneal lavage: Thorough washing to reduce contamination.

7.Drainage: Place drains if necessary to manage contamination.

8.Postoperative care: Monitor hemodynamics, prevent infection, support nutrition and motility.

Signs of Intestinal Viability (Intraoperative):

Color: Healthy pink or red; non-viable appears dark, black, or greenish.

Peristalsis: Present in viable bowel, absent in necrotic segments.

Mesenteric arterial pulsation: Palpable pulsation indicates perfusion.

Bleeding from cut edge: Indicates viable tissue.

Response to warming: Viable bowel improves color and peristalsis after warm saline application.

Limits of Resection:

Proximal margin: At least 40–60 cm away from the obstruction site, in healthy tissue.

Distal margin: At least 10–15 cm beyond the obstruction in healthy bowel.

Resect until all questionable or ischemic tissue is removed to prevent postoperative complications.

Ensure good blood supply and viable margins for anastomosis.

20.Preoperative preparation and postoperative management of patients with acute intestinal obstruction.

Preoperative Preparation for Acute Intestinal Obstruction:

1.Nasogastric/intestinal decompression: Immediate insertion of a nasogastric tube for continuous aspiration to prevent aspiration pneumonia and reduce intraluminal pressure.

2.Fluid and electrolyte correction: Aggressive intravenous isotonic fluids

(e.g., Ringer’s lactate), correcting dehydration, electrolyte imbalances

(especially potassium), and acid-base disturbances.

3.Monitoring: Insert central venous catheter to monitor central venous pressure and guide fluid therapy; place Foley catheter to monitor urine output (aim >40 ml/h).

4.Broad-spectrum antibiotics: Start preoperatively, especially if strangulation or perforation is suspected, to prevent or treat bacterial translocation and sepsis.

5.Hemodynamic stabilization: Correct shock and restore circulating volume; transfuse blood products if necessary.

6.Laboratory and imaging: Obtain labs (CBC, electrolytes, coagulation), and radiological confirmation (X-ray, CT).

7.Consent and anesthesia evaluation: Inform patient/family; ensure readiness for emergency surgery.

Postoperative Management:

1.Respiratory care: Prevent atelectasis with incentive spirometry, early mobilization.

2.Continued decompression: Maintain nasogastric or nasoenteric suction until bowel function returns.

3.Fluid and electrolyte management: Continue IV fluids to maintain hydration and electrolyte balance; monitor urine output.

4.Pain control: Use appropriate analgesia, avoiding opioids that delay bowel motility when possible.

5.Infection prevention: Continue antibiotics as indicated; monitor for signs of peritonitis or abscess.

6.Early mobilization and thromboprophylaxis: Use elastic stockings, low molecular weight heparin to prevent DVT/PE.

7.Nutritional support: Start parenteral nutrition if prolonged ileus; transition to enteral feeding once bowel function returns.

8.Monitoring: Watch for signs of anastomotic leak, persistent ileus, or sepsis.

9.Stimulate bowel motility: Consider prokinetics or anticholinesterase agents and bowel electrostimulation if needed.

Peritonitis

1. Peritonitis. Concept, etiopathogenesis.

Peritonitis is an inflammatory process affecting the visceral and parietal peritoneum, typically accompanied by exudation and systemic manifestations.

Key Characteristics:

Inflammation occurs in a closed, anatomically complex cavity.

Rapid spread due to diaphragmatic movements and intestinal peristalsis.

Neuroreceptor irritation leads to paralytic ileus.

The inflamed peritoneum retains resorptive capacity, contributing to systemic intoxication.

Etiopathogenesis

Etiology: