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jejunogastric intussusception. Occasionally, endoscopy is needed to
clarifythepicture.Dounderstandthatacuteafferentloopobstruction
isadireemergency—youhaveto operatebeforetheclosedloop
obstructionresultsincompletenecrosisoftheduodenum!
Atoperationtheanatomyhastoberestoredandthisentailsresection
of non-viable loops of bowel and reconstruction of the upper
gastrointestinaltract,asyouwoulddoafterpartialortotalgastrectomy.
Smallbowelvolvulus
Thisis alsocalled ‘midgutvolvulus’— distinguishingit from‘foregut
volvulus’( Chapter16)and‘hindgutvolvulus’( Chapter27).
Volvulus —thetwisting strangulation ofanintestinal segment around
an axis formed by a band or an adhesion is a common occurrence in
adhesive SBO. A narrow-based loop of small bowel suspended by a
Meckel diverticulum can also undergo torsion. But what about
‘spontaneous’volvulus — one that involves the entire, or almost entire,
smallintestine?
Spontaneous volvulus of the small bowel, while very rare in the
developed world is not uncommon in rural areas of the Indian
subcontinent,centralAsiaandAfrica.Itseemsmorecommoninhealthy
farmersreturninghomeforalargeeveningmealor,inMuslimcountries,
duringthefastofRamadan—whenlargemealsareconsumedatnight
afterthedayoffasting.Thecommonpathwayappearstobeahugeload
ofhigh-fiber,indigestiblefood,arrivingsuddenlyinanemptysmallbowel.
Thesuddendistensioncreatesrotational-kinkingforces.
At operation, typically the twisted bowel is loaded with liters of
clay-likeundigestedfoodand is often suspended on anunusually
long mesentery. Occasionally, small bowel volvulus occurs in
combination with that of the sigmoid colon, forming the so-called
ileosigmoidknotwheretheileumandthesigmoidentangleeachother
to form a knot and become gangrenous. An arrangement of the small
bowelandsigmoidcolononlong,narrowmesenterieswouldappearto
beaprerequisite.
Asinanyotherconditionresultinginacutevascularcompromiseofthe
bowel, patients present with severe central abdominal pain that is
out of proportion to the abdominal findings; additionally, systemic
signsofhypovolemiaandtoxemiaaredramaticanddominant.Anurgent
operationisindicatedduringwhichtheischemicintestineismanagedas
discussedabove.
Intestinalmalrotation
Most cases of midgutmalrotation present within the first weeks or
months of life. The rest can present sporadically throughout childhood
and even in adults. The anatomy of malrotationis depicted in Figure
21.3:note howclose the D-Jflexure (pointX)is tothe cecum (pointY)
andhownarrowthebaseofthemesenteryis,andthuspronetotorsion.
Strangulatingmidgutvolvulusinthesepatientscanpresentacutely,but
more commonly, especially in older children and adults, volvulus is
preceded by recurring attacks of upper and central abdominal colicky
pain,intermittentvomitingofbileandisoftenrelievedbydiarrhea.Once
again, patients presenting with acute midgut volvulus are in great pain
andappearillbuthaveminimalabdominalfindingsonexamination!
Classically, the diagnosis was achieved by contrast studies: upper
gastrointestinal barium examination showing loss of the ‘duodenal C’
(corkscrew duodenum) and the D-J flexure to the right of the midline.
Barium enema would show the cecum riding high under the liver. CT
howeverhasbecometheoptimaldiagnosticmodality showing the
smallbowellocatedentirelywithintherighthemi-abdomenandthe
colon situated on the left. Features of the twisted mesentery and
intestinal wall ischemia are also seen. Midgut volvulus can also be
diagnosedonDopplerultrasoundbydemonstratingthe‘whirlpoolsign’—
wrappingofthe superiormesentericvein andthemesenteryaroundthe
superiormesentericartery.
Emergency laparotomy is mandated. Remember that these patients
are grossly hypovolemic and need aggressive fluid resuscitation. At
operationdetortthetwistedbowelworkinginacounterclockwiserotation.
Ischemicdeadbowelneedsresection—usuallymassiveresection.Fora
discussiononwhethertoanastomoseornotandwhetherasecond-look
operationisnecessary—lookat Chapter24.
Figure21.3. a-c) Small bowelmalrotationand volvulus; ci) normal;cii) malrotation; and
ciii)followingLadd’sprocedure.X=D-Jjunction;Y=cecum.Modifiedfrom:YoungsonGG.
CommonPediatricDisorders.RoyalCollegeofSurgeonsofEdinburgh,1998.
Afterresectingthedeadbowel,orconvincingyourselfthatitisviable,
you need to address the anatomical pathology of malrotation by doing
whathasbeendescribedbyWilliamE.Ladd.
1.Dividetheperitonealfolds(Ladd’sbands)thatcrossfromthececumtotheliver,
compressingtheduodenum.
2.Mobilizetherightcolon.
3. Mobilize the D-J flexure, freeing the ligament of Treitz — straightening the
duodenalloop.
4.DivideanythickperitonealfoldscompressingtheSMA.
5.Place the bowel in anew pattern as depicted in Figure 21.3ciii — note that
nowpointXisfarfrompointY.
6.Removetheappendixtoprevent‘atypicallysituated’appendicitis.
Obviously, after having to resect most ofthe smallbowel you donot
needtoworryaboutrecurrenceofthevolvulusandthereisnoimpetusto
correcttheanatomy,exceptatpoints1,4,6.
Prognosis
Overall,abouthalfofpatientspresentingwithanadhesiveSBOcanbe
managed without an operation. About a third of patients operated on
onceforadhesiveSBOwillhaverecurrentproblemswithin30years.For
patients admitted several times for adhesive SBO, the relative risk of
recurrence increases with the increasing number of prior obstructive
episodes — more than two-thirds of patients with four or more SBO
admissionswillreobstruct.Theriskofrecurrenceisabitlowerinpatients
inwhomthepreviousobstructiveepisodewastreatedsurgicallybutthis
doesnotmean that those patients who were treated conservativelywill
havean increased needforoperation during theirfuture admissions for
SBO.Theaimisthereforetooperateonlywhennecessary,butnot
todelayanecessaryoperation.
In our minds, anyone who discovers a viable solution to prevent
adhesiveSBOwoulddeserveaNobelPrize.TheguysfromUppsalamay
thinkotherwise.
“The only thing predictable about small bowel
obstructionisitsunpredictability.”
1
Schein’s Common Sense Prevention and Management of Surgical Complications.
Shrewsbury,UK:tfmpublishing,2013:Chapter23.
2
ThissectionisbyDanny.
Chapter22
Acuteabdominalwallhernias
PaulN.Rogers
Always explore in cases of persistent vomiting if a lump,
however small, is found occupying one of the abdominal
ringsanditsnatureisuncertain.
AugustusCharlesBernays
Acutegroinhernia
Inallpartsoftheworldmostgroinherniasarenowrepairedelectively.
In spite of this, surgeons are still frequently confronted by acute groin
herniasanditisimportantthatyouknowhowtodealwiththem.
Somewordsabout terminology: groin hernias, inguinal or femoral,
maybedescribedasreducible,irreducible,incarcerated,strangulated,or
obstructed. This terminology can be confusing and thesewords, which
have come to mean different things to different people, are much less
important than the concepts that underlie the recognition and
management of acutehernia problems. The important concept to be
graspedisthatanyherniathatbecomespainful,inflamedortender
—andisnotreadilyreducible—shouldberegardedasasurgical
emergency.
Presentation
Patientsmaypresentacutelyinoneoftwoways:
•
Symptomsandsignsrelateddirectlytotheherniaitself.
•
Abdominalsymptomsandsigns,which atfirst maynot seemto be
relatedtoahernia.
Thefirstmodeofpresentationusuallymeanspainandtendernessin
a tense, irreducible hernia. Apreviously reduciblehernia may suddenly
becomeirreducible.Thisproblemisusuallyobvious( Figure22.1).
The second mode of presentation may be much more insidious.
Bewarethevomitingoldlady!Treatedathomeforseveraldaysbythe
primarycarephysicianasacaseofgastroenteritis,sheeventuallycomes
underthe careof thesurgeons dueto intractableemesis.Bythisstage
sheis dehydratedand inneed ofmuchresuscitation.Itissurprisingly
easyinthesecircumstancestomissthesmallfemoralherniabarely
palpable in the groin, trapping just enough small intestine to
produceobstruction.Noabdominalsymptomsorsignsarepresentand
the plain abdominal radiographs are non-diagnostic. None of these
difficultiessavesyoufromtheembarrassmentofthefollowingmorning’s
roundwhentheherniaisdiscovered.
Figure22.1.“Thismustbestrangulated,eh?”
ThesedaysitiscommonlydiscoveredbythemandatoryCTscan.Danny
Hernias are still one of the commonest causes of small bowel
obstruction ( Chapter 21). You must look carefully for them in all
cases of actual or suspected intestinal obstruction. This may mean
meticulous,prolongedanddisagreeablepalpationofgroinsthathavenot
seenthe lightof day,letalonesoapand water, fora longtime. Inmost
cases, however, the diagnosis is obvious with a classical bowel
obstructionandaherniastuckinthescrotum.
BewaretheRichter’shernia—typicaloffemoralhernias,whereonly
aportionofthecircumferenceofthebowelisstrangulated.Becausethe
intestinal lumen is not completely blocked, bowel obstruction may not
occurandpresentationisconsequentlydelayedandnon-specific.
Preparation
Surgeryforacutegroin herniaproblemsshouldbecarriedoutwithout
undue delay, but these patients must not berushed to surgery without
careful assessment and preparation. As we suggested earlier, some
patients may be in need of quitea bit of resuscitation onadmission to
hospital.Quite oftenthesepatientsstillhaveaherniabecausethey
have been deemed ‘unfit’ for elective repair; comorbidity in this
groupofpatientsmaybeasignificantproblem.
Analgesia is animportant part of the management of these patients.
Opiateanalgesia and bed rest with thefootof the bed slightly elevated
may successfully manage a painful obstructed herniaof short duration.
Gentleattemptsatreductionofsuchaherniaarejustifiedoncethe
analgesics have taken effect. A successful reduction of the hernia
meansthatemergencysurgeryatunsociablehoursmaybetradedfora
semi-electiveprocedureonthenextavailableroutinelist—abenefitfor
both patient and surgeon. Note that manual reduction of the
incarcerated hernia should be attempted only in the absence of
signs of intestinal strangulation; it should be gently performed, to
avoid reduction en masse — when the herniated bowel and the
constricting ring are reduced together, providing a false sense of
achievementandadelayofnecessarysurgery.
Theoperation
Inguinalhernia
Thechoiceofanesthesia—whetherlocal,spinalorgeneral—isupto
you, the habitus of the patient and your institutional dogmas. But we
preferdoingthesecasesunderlocalanesthesia(andi.v.sedationbythe
anesthetist) which is also our practice in the elective situation. An
inguinal incision is a satisfactory approach. Even if a bowel
resection is required it is possible to deliver sufficient length of
intestinethroughthelimitedincision.
The main difference in dissection in an emergency hernia operation
compared to anelective procedure is the moment at which the hernial
sac is opened. In the emergency situation the hernia will often reduce
spontaneously as soon as the constricting ring is divided. The site of
constrictionmaybethesuperficialinguinalring,inwhichcasethehernia
reduces when external oblique is opened. It is recommended,
therefore,thatthesacbeopenedandthecontentsgraspedforlater
inspectionbeforetheconstrictingtissuesarereleased.Ifthe hernia
reducesbefore the sac contents are inspected, it is important that they
aresubsequentlyidentifiedandretrievedsothataloopofnon-viablegut
isnotinadvertentlyleftintheabdomen.Retrievalofreducedsaccontents
can be an awkward business via the internal ring and occasionally a
formal laparotomy may be required to inspect mattersproperly. It is for
thesereasonsthatgreatcareshouldbetakentosecurethesaccontents
forinspection assoon aspossible duringtheprocedure.Inthismodern
era of laparoscopy, it may be possible to inspect the reduced sac
contents by insertion of the scope via the hernia sac if this should be
necessary.
When the hernia sac contains only omentum, any tissue that is
necrotic, or of doubtful viability, is excised, ensuring meticulous
hemostasisinthe process— evenatinybleederfrom thestumpofthe
resectedomentummaybringyoubacktotheOR!If,ontheotherhand,
bowel is involved, then any areas of questionable viability should be
wrapped in a warm moist gauze pack and left for a few minutes to
recover.Irreversiblyischemic gutshould beresected. Ifthere isasmall
patch of necrosis thatdoes not involve the whole circumference of the
bowelthenthiscansometimesbedealtwithbyinvaginationratherthan
by resorting to resection. In this situation the injured bowel wall is
invaginatedbyaseromuscularsuture,takingbitesontheviablebowelon
eithersideofthedefectiveareaofgut.
Occasionally,particularlyifbowelresectionhasbeennecessary,
edemaoftheherniatedgutmakesits replacementintheabdomen
difficult. Maneuvers such as putting the patient into a marked
Trendelenburg position and gently compressing the eviscerated gut,
covered by a large moist gauze swab, will almost invariably allow the
bowel to be replaced in the abdomen. It is possible to minimize the
chances of this difficulty arising if care is taken during any bowel
resection not to have any more gut outside the abdomen than is
absolutely necessary. Very rarely, the herniated viscera won’t return to
the abdomen without pulling on it from within; in such instances La
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