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29 Short Bowel Syndrome
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The Intraoperative Consult
H. Randolph Bailey and Terah C. Isaacson
3 0
Key Points
• Careful assessment and good operative exposure
are key steps in preparing for any operation.
• Do not compromise known surgical principles or
sound judgment in order to satisfy a requesting
physician.
• Most of the situations that you will encounter will
be similar to something you have seen in the past;
use your experience and build upon it.
Initial Mindset
Key concept: Gather your thoughts and as much information
about the patient as quickly as possible, then rely on your
past experiences and sound judgment.
The busy schedules of surgeons rarely afford a free moment,
and, in fact, the call for assistance from a colleague in the operating room often comes when you are the most involved in the
care of your own patients. When you receive the phone call for
an intraoperative consultation, you must make a determination
as to how to deal with your own schedule. It is important to
understand the immediacy of the need for your help. At times,
an injury may have occurred during a gynecological procedure
that can be addressed in an hour or two at the end of that pro-
cedure. In the case of signifi cant bleeding or an unstable
patient, a more immediate need is required and you must
notify (apologize to) your patients accordingly.
Between the time of the call from the consulting surgeon
and your arrival in the operating room, a lot of potential scenarios can go quickly through your mind. By calling upon
similar situations that you have encountered in the past, you
may develop a plan of management with multiple alternatives. It is important to rapidly obtain as much information as
possible. These include demographic information, indication
for the operation, prior surgical history, type of operation,
and the circumstances surrounding the need for consultation.
You should try and obtain the patient’s imaging and endoscopic history to better understand the current situation. A
quick review of recent images may give you an idea about
previous surgeries and additional pathology that may warrant consideration. All of these details will allow you to start
to visualize the expected operative fi ndings, associated complexity, as well as the possibilities of anatomic variations. In
the case where minimal or no history is available, approach
the patient with consideration of their age, body habitus, and
assessment by the requesting physician and anesthesiologist
of their current state of health.
Another very important consideration is your prior relationship with the consulting surgeon and your thoughts on
his/her judgment and technical abilities. Your experience as a
specialist has likely put you in a position where you have seen
many of these challenges before, so try to replay in your mind
those experiences and what made the outcomes successful.
H. R. Bailey , MD, FACS (*)
Division of Colon and Rectal Surgery ,
The University of Texas Health Science Center,
Houston Methodist , 6550 Fannin St, Suite 2307 ,
Houston , TX 77030 , USA
e-mail: hrbailey@swbell.net
T. C. Isaacson , MD
Division of Colon and Rectal Surgery ,
Houston Methodist , 6550 Fannin St, Suite 2307 ,
Houston , TX 77030 , USA
e-mail: cterah@gmail.com
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_30, © Springer Science+Business Media New York 2014
Initial Evaluation
Upon entering the operating suite, the situation must be rapidly assessed. This includes obtaining information from the
anesthesiologist on the stability and ASA status of the patient
and type of antibiotics given and when. If bowel resection
was not a planned procedure, it must be confi rmed that the
patient has received coverage of enteric gram (−) bacilli,
463
464
H.R. Bailey and T.C. Isaacson
Fig. 30.1 Draping technique to facilitate exposure to the perineum
Enterococcus and anaerobes. Timing must also be consid-
ered, and another dose of “bowel appropriate” antibiotics
may be indicated depending on the initial antibiotic choice
and its timing [ 1 ].
Positioning
Key concept: Don’t be afraid to change the patient’s position
to help accomplish what you need to do.
Evaluate the position of the patient. Depending on the reason for the consultation, it may be useful to move the patient
from supine to low lithotomy position. This can frequently
be done without contaminating the abdominal incision and is
relatively easy to accomplish if you help the staff with posi-
tioning. You must identify the location of the patient on the
operating table and make sure that all connections including
those for self-retaining retractors are free prior to moving the
patient down on the table. Stirrups or low lithotomy boots
can be placed on the sides of the table, legs put into position,
and the sterile drape cut down the middle. Sterile leggings
can then be placed over the drape and will allow for excellent
exposure to the anus, rectum, or pelvis if needed (Fig. 30.1 ).
The low lithotomy position allows for endoscopic evaluation
of the rectum (and possibly the entire colon), placement of
ureteral stents, transanal insertion of stapling devices for an
anastomosis, and anastomotic testing.
Initial Survey
A survey of the available instrumentation, possible endoscopic or radiologic needs, and additional available staff
should be addressed with the operating room personnel. In
years past, when I traveled to multiple hospitals, I used to
carry a set of “special” instruments in my car. The basic
operating instruments are now available in most hospitals. In
the cases of endometriosis that cannot be differentiated from
rectal cancer or other situations requiring identifi cation or
localization of lesions, rigid proctosigmoidoscopy or fl exible
sigmoidoscopy can be very helpful. To gain a better understanding of the anatomy and allow planning your approach,
you may even consider doing these procedures prior to
scrubbing. Rarely is radiology necessary beyond confi rming
instrument and sponge counts. You may fi nd the need for
ureteral stents to be placed. The lithotomy position facilitates
stent placement. If you are not in a hospital where you work
frequently, asking the consulting surgeon for their choice of
urologist may be wise.
Examination
Key concept: Don’t just focus on the problem at hand, but the
entire situation. Establish roles early.
Once at the patient’s side, look fi rst at the problem for
which you are consulted. Next, evaluate the rest of the
abdominal viscera including the extent of adhesions and the
magnitude of any injury present. The length of the remaining
small bowel and its accessibility are important. After appraising the situation and the interventions required, you must
determine whether you will assume control of the case or
“assist” the requesting physician. If the consulting surgeon
needs assistance with adhesiolysis for improved exposure of
return the operation to the primary surgeon for completion.
If, on the other hand, there is a signifi cant bowel injury or a
need for bowel resection, then I would assume primary control of the operation and often the postoperative care. Again,
this has a lot to do with my prior relationships with the primary surgeon.
Exposure/Operative Procedure
Key concept: You should be familiar with several methods to
extend your incision and provide adequate exposure.
After deciding what needs to be done, you must determine
if the exposure is adequate to perform the indicated procedures. The beauty of a midline incision is that it can be
extended as needed. If you have a Pfannenstiel incision and
need greater exposure, it can be enlarged by conversion to a
Cherney incision. This involves extending the fascial incision
to the pubic tubercles laterally and dividing the tendonous
attachments of the rectus abdominis muscles to the pubic
crest [ 2 ]. Additionally, the Maylard incision divides the rec-
tus muscle to facilitate improved exposure, but is limited to
the lower part of the peritoneal cavity (Fig.
30.2a–d ). If the
30 The Intraoperative Consult
a
Incision
b
Maylard
incision
Rectus
fascia
cd
465
Rectus muscle
cut by cautery
Fig. 30.2 ( a–d ) Maylard incision technique
upper abdomen requires signifi cant attention that cannot be
reached through the lower incision, it may be necessary to
convert to a midline incision extending up as high as necessary. This is referred to as an “inverted T” incision and may
provide good exposure for the entire abdomen [ 3 ]. Another
Peritoneum
opened by
cautery
approach is the “hockey-stick” incision. This is created by a
vertical incision at the lateral aspect of the lower transverse
incision. It is made lateral to the rectus muscle, which is usually divided. The incision can be extended upward to the costal margin, if needed, for further exposure [ 4 ].
466
H.R. Bailey and T.C. Isaacson
Common Intraoperative Consults
Extensive Adhesions
Key concept: Meticulous dissection and knowing when to
divert avoid additional problems.
One situation that you may encounter is that of dense adhesions that prevent access to a surgical site. What seems like a
diffi cult situation to the surgeon who does not deal with bowel
on a daily basis may be relatively straightforward to the experienced GI surgeon. In the face of diffi cult and tedious adhesions, careful and patient adhesiolysis will often be rewarded
by a good result regardless of etiology. In performing a diffi cult adhesiolysis, it is usually better to leave a bit of peritoneum or fascia on the bowel rather than risk an enterotomy.
Another technique used by those facile with knife dissection
is to use a blade rather than scissors to divide adhesions.
A patient who has had very recent abdominal surgery may
have fusion of tissue planes between the small bowel and
surrounding structures. In this circumstance, if it is not possible to safely separate the loops with careful dissection, it
may be best to perform some type of intestinal diversion and
a gastrostomy with plans for intravenous nutrition and return
in 6–12 weeks for a repeat operation.
Injury to Large or Small Bowel
Key concept: The extent of injury will help determine the
degree of repair or resection required.
The calls for injury to the bowel that cannot be repaired
by the primary surgeon typically come from the gynecologist
or urologist due to their lack of comfort with bowel surgery.
Most small bowel injuries can be resected or repaired primarily. You must properly examine each injury by fully
mobilizing the area of involved bowel. It is diffi cult to establish “rules” as to when to repair serosal or seromuscular injuries. Typically, I do not repair simple serosal injuries. This is
due to the fact that the major strength of the bowel wall
comes from the submucosa, with only minimal contributions
from the serosa and muscular layers [ 5 ]. If the muscularis
has also been stripped from the submucosa and there is bulging of the mucosa, I will often repair. Milking the bowel content past the area of injury will often help identify an area of
full-thickness injury as well as the adequacy of the repair. To
avoid narrowing the bowel, I try to close the defects transversely with interrupted Lembert sutures. I then return at the
end of the procedure and carefully inspect the repair for evidence of ischemia. If it looks questionable or ischemic, I
would favor segmental resection. With electrosurgical injuries, it can be diffi cult to evaluate the depth or extent of the
thermal damage and the potential exists for delayed perforation. The simplest and safest approach is imbrication of the
site of potential injury with a series of Lembert sutures as
described above [ 6 ]. In situations where there is concern for
breakdown of repair, malnutrition, and steroid use, a drain
left near the repair can potentially establish a controlled fi stula. Once the entirety of the abdominal viscera has been
evaluated, it becomes important to assess the remaining
length, particularly of the small bowel. Those who have had
a signifi cant amount of their small bowel resected may be at
risk for short bowel syndrome [ 7 ].
For colonic injuries, the same decisions must be made, to
resect or repair. These situations should be handled similar to
a trauma setting. There are several studies that support the
primary repair of injuries that involve <50 % of the bowel
wall and have no evidence of devascularization. If there are
perforations or injuries that involve >50 % of the bowel wall,
result in complete transection, and have signifi cant tissue
loss or evidence of vascular compromise, resection should
be undertaken. The experience from the University of
Tennessee has shown that in these patients a management
algorithm based on patient comorbidities and transfusion of
greater than six units of blood can help determine the operative approach. They suggest that patients with chronic renal
failure, congestive heart failure, HIV, and cirrhosis and those
on chronic steroids or who have been transfused more than
six units of blood should be diverted. Otherwise, resection
and primary anastomosis is typically safe [ 8 ].
Special circumstances include the presence of multiple
colonic injuries and injuries that are proximal to an anastomosis. You may perform a resection of one colonic injury,
but may not be able to include them all, leaving questionable
bowel to be addressed. The use of omental patches may be
useful to cover or reinforce these types of injuries. The use of
serosal patches (suturing another segment of healthy bowel
over an injury) has been described, but I have used this technique very rarely. Fibrin glue has also been employed to
reinforce bowel repairs with variable results [ 6 ]. Another
acceptable approach is repair and proximal diversion. An
adjunctive maneuver when dealing with colonic repairs in an
unprepared colon is the milking of solid stool into a segment
of colon that is to be resected. This will decrease the amount
of stool remaining in the bowel, particularly proximal to an
anastomosis.
Injury to Rectum
Key concept: While diversion plays a larger role with rectal
injuries, factors such as the location of the injury, patient’s
clinical status, tissue health, and degree of contamination
are extremely important in decision-making.
Rectal injuries are among the more common reasons for
intraoperative consultation. Whether or not the patient has
had pelvic radiation, dates of administration and the dose
30 The Intraoperative Consult
467
Fig. 30.3 Rectosigmoid perforation from a prior colonic stent
(Courtesy of Philip Y. Pearson, MD)
given are important details for safe operative decisionmaking. The timing of the radiation is at least as important as
the dosage. Beyond 8–12 weeks, intimal fi brosis and thickening may lead to a decrease in blood fl ow to and impaired
healing of the radiated segment of bowel. Performing a proximal diversion or bringing in well-vascularized tissue to buttress the repair of radiated bowel should be considered.
Possibilities for such reinforcement include an omental pedicle or muscle fl aps such as gracilis or rectus abdominis.
These can also be valuable techniques to use in patients who
have an injury to the rectum during a hysterectomy.
Interposing tissue such as the omentum between the rectal
repair and fresh vaginal cuff may reduce the incidence of
postoperative rectovaginal fi stula formation.
As in colon injuries, much of the decision-making in rectal injuries is similar to that in the treatment of trauma. The
mechanism of injury is of importance whether it be sharp,
avulsion, or thermal (Fig. 30.3 ). The amount of contamina-
tion, the stability of the patient, and whether the injury is
intraperitoneal or extraperitoneal are also of consideration. If
a bowel injury is nondestructive and in the upper one-third of
the rectum (intraperitoneal), these can safely be managed
with primary repair and selective diversion depending on the
circumstances of the consult. In the lower two-thirds of the
rectum (extraperitoneal), injuries should be debrided to
healthy tissue and repaired; if possible, a presacral drain
(brought out through the abdominal wall) and diversion
should be considered [ 9 ]. If the patient is unstable, has
received several transfusions, or is medically unfi t, diversion
should be very strongly considered. Additionally, I may have
a lower threshold to divert in a consulting situation than I
would in an operation where I am the primary surgeon. This
holds true because you may or may not know every clinical
aspect of the case and you want to do the safest thing possi-
ble. The patient may have issues with incontinence that no
one has addressed, and creating a low colorectal anastomosis
may exacerbate this.
Mass
Key concept: In the absence of obstruction, obtaining issue
and returning at a future time with more information and
discussion with the patient are often benefi cial.
The operating surgeon may encounter a mass either by
palpation of the colon during routine exploration or in an
extraluminal location with involvement of the bowel. In the
initial evaluation of the mass, the degree of obstruction that is
present must be determined. If obstruction is not an issue or
malignancy can be ruled out (as in endometriosis), it may be
best to return at another time after proper bowel evaluation
and after obtaining informed consent from the patient. If
obstruction is present in the colon and it has not been prepped,
the risk of contamination and anastomotic problems should
be considered. At this time, my preference remains in favor
of bowel preparation for elective cases. In the consulting situation, if the patient has not been prepped, I am willing to do
anastomoses without bowel preparation in light of the data
that have shown no increased complications. A Cochrane
Review performed in 2011 showed no statistically signifi cant
evidence that patients benefi t from mechanical bowel preparation nor the use of rectal enemas [ 10 ]. In addition, one
study showed that the liquid stool present in patients that had
bowel preps caused a signifi cantly higher rate of spillage and
therefore could lead to a higher rate of infection [ 11 ]. As
mentioned previously, solid stool can be maneuvered into the
portion to be removed to decrease the amount of stool burden
proximal to your anastomosis. It must be remembered that
the data regarding colonic resection and bowel preparation do
not apply to situations where the bowel is obstructed. The
intestine proximal to an obstruction is typically dilated and
congested, and I feel that anastomosis to such a segment of
bowel is dangerous. If the bowel is resected back to healthy
small bowel, an anastomosis can still be considered. A bypass
may also be considered if the mass is unable to be removed.
If the mass is extraluminal and not causing obstruction,
biopsy should be performed to determine the nature of the
problem as well as to determine the presence of possible
malignancy. Removal can be considered if the risks do not
seem excessive. In addition to adenocarcinoma, other less
frequent fi ndings on biopsy include endometriosis (which
will be discussed later), carcinoid, desmoid, lymphoma, and
necrotic tissue (such as a lymph node). Carcinoid frequently
involves the appendix or terminal ileum. Resection is frequently safe and advisable for carcinoid tumors. Remember
that ileal carcinoids are often multiple, so careful examination of the adjacent bowel is advisable. Desmoid tumors are
468
H.R. Bailey and T.C. Isaacson
seen most frequently in patients with familial adenomatous
polyposis and can involve the mesentery or the abdominal
wall. My general approach to desmoids would be not to
resect. Smaller lesions on the abdominal wall may be safely
removed, but with nonobstructing smaller lesions involving
the mesentery, the fi rst line of therapy is often medical with
sulindac and anti-estrogens. Larger desmoids may be diffi cult to remove safely due to the involvement of mesenteric
vessels and often result in signifi cant portions of bowel being
resected. These are best treated with chemotherapy [
12 ].
Isolated gastrointestinal lymphomas rarely cause obstruction or perforation due to their pliable nature and most often
present with acute abdominal pain. They should be resected
for potential cure, staging information, and avoidance of complications. A recent review of primary small bowel and colonic
lymphoma showed that small bowel lymphoma did benefi t
from postoperative chemotherapy. Colorectal lymphoma on
the other hand did not show a signifi cant difference with chemotherapy or surgery alone as most required surgery for complications or diagnosis [ 13 ]. Necrotic lymph node tissue may
need to be debrided, but does not need to be resected to clear
margins. This may be an indication for a drain.
Colonic Infl ammation
anastomosis can be performed [
14 ]. A proximal diverting
stoma, colostomy, or loop ileostomy may be added depending on the condition of the patient and the bowel.
Right lower quadrant pain can also mimic other disease
states of an infl ammatory nature. General surgeons operating
for appendicitis often encounter these situations. The fi nding
of diverticulitis of the right colon or appendix is rarely diagnosed correctly preoperatively, with most patients being
diagnosed with appendicitis. Appendectomy with or without
diverticulectomy followed by antibiotics is appropriate for
infl ammation of a diverticulum. If there is localized abscess,
perforation, or concern for cancer, a right hemicolectomy is
the procedure of choice [
15 ].
Another diffi cult situation is the patient with right lower
quadrant pain, neutropenia, and, sometimes, even sepsis.
Oftentimes in neutropenic enterocolitis, the most diffi cult
decision is when to take the patient to the operating room,
and if you are being consulted intraoperatively, this decision
has already been made. Most literature is based on retrospective case series, but do show a trend toward improved outcomes with surgery. Most authors recommend a right
hemicolectomy as the mucosal injury can be more extensive
than the serosal surface reveals. An end ileostomy with
mucous fi stula would be the safest approach in this situation
involving immunosuppression and potential sepsis [ 16 ].
Key concept: Many infl ammatory conditions can be treated
medically, while perforations should be repaired at the time.
These consultations usually arise in the setting of pelvic
surgery, typically gynecological or urologic procedures.
They may also arise in the setting of right lower quadrant
pain and immunosuppression. The sigmoid or descending
colon may be noted to have infl ammation or be adhered signifi cantly to structures of interest to the requesting surgeon.
It is important to note that infl ammation of the colon in the
face of diverticulosis may be related to a variety of colitides
that may best be treated medically. Therefore, infl ammation
of the colon, by itself, is not an indication for resection.
Purulence is often encountered. Most of these patients have
been asymptomatic as far as episodes of acute diverticulitis
are concerned. A detailed history, if available, is helpful in
these situations. This is often not readily available, and discussions with family members may or may not yield any
additional clinical information.
In general, simply following sound surgical principles
applies. A perforation associated with diverticular disease
can be identifi ed with air insuffl ation by inserting a rigid
proctoscope and examining the air-fi lled bowel with saline in
the pelvis. If no air leak is identifi ed and there is minimal to
no contamination, often times the diverticulitis can be
observed with appropriate antibiotic coverage. This may be
combined with intra-abdominal drains depending on the
comfort level of the operating surgeon. In the face of perforation without gross contamination, a resection with primary
Cancer and Polyps
Key concept: Proper lesion location and adherence to oncologic principles such as en bloc resection is imperative.
Other situations may be best handled by closing the patient
and obtaining appropriate staging information.
Several issues can arise in operations for malignant processes of the colon and rectum. A common intraoperative
consult is the call for assistance in locating a mass. In the
colon, this can occur if the lesion was not tattooed or the
endoscopist experienced looping of the scope resulting in
inaccurate localization. The diffi culty in identifying distal
lesions of the large bowel may be the variation that can occur
with measurements obtained by fl exible versus rigid instruments. If the operating surgeon did not confi rm the location
prior to the abdominal operation, the fi rst step is to place the
patient into low lithotomy and examine thoroughly with a
fi nger, rigid proctoscope, or even a fl exible sigmoidoscope
or colonoscope depending on the likely location of the mass.
If the operation is being done laparoscopically, it may be
prudent to convert to a hand-assisted or open technique.
Intraoperative colonoscopy may be diffi cult in a laparoscopic procedure due to massive distention of the colon. In a
hand-assisted operation, it may be possible to pass the scope
through the colon with minimal insuffl ation. Then, short segments of the colon can be insuffl ated and decompressed with
the aid of the intra-abdominal hand. CO 2 insuffl ation has
30 The Intraoperative Consult
469
been described, but may be diffi cult to setup unless you have
worked out the details of the technique in advance. Also, the
CO
absorbs more rapidly than room air, but still may keep
2
the bowel distended making resection more diffi cult.
Methodical palpation of the colon can also aid in locating the
mass. Once the lesion is identifi ed, you may have fi nished
your consultation. If, on the other hand, the lesion is not
identifi ed even after these maneuvers, it may be prudent to
close the patient and reevaluate at a later date.
Another circumstance which may arise is the cancer that
is located much lower in the rectum than the operating surgeon expected, and he/she is not comfortable performing the
resection at that level. This becomes a situation in which
(unless you are consulted by your partner or someone in your
rounding group) you must become the primary surgeon and
decision-maker. Standard principles for resection of rectal
cancer should apply, and the need for neoadjuvant therapy
should be considered. It may be best to close the abdomen
and refer the patient for neoadjuvant therapy if this has not
been done. This decision should be made before mobilizing
the rectum since a second attempt at mobilization is much
more diffi cult and dangerous. If the staging of the rectal
tumor is not clear, intraoperative ultrasound can be performed to assist in determining if the patient would be a candidate for such therapy. This may be a situation where you
may wish to discuss the case with the family prior to going
forward with any intervention and fully discuss the risks and
benefi ts of the indicated procedure.
Another common issue that arises is the presence of cancer in other organs that unexpectedly appears to be invading
the large or small bowel. This can occur with urologists
when operating on the bladder or prostate as well as with
gynecologists operating for pelvic tumors (Fig. 30.4 ). Less
common is for a right colon cancer to invade either the duodenum or pancreas (or vice versa). It is key to understand the
typical behavior of the primary cancer, the type of preoperative therapy that has been given, and the expected outcome
of therapy. If the surgery is for palliation and resection of the
bowel would involve major vessels or other substantial morbidity, it may be prudent to opt instead for a bypass procedure or diversion. If the patient is healthy and the resection is
for cure in a fi eld that has not been radiated, an en bloc resection of the primary tumor and adjacent organs should be the
goal. These situations will be widely variable, but using your
best surgical judgment and following sound surgical principles will achieve the best results.
Endometriosis
Key concept: Resect all visible disease with a disc excision
or segmental resection when possible.
As colorectal surgeons, we work closely with gynecologists and especially those with an interest in endometriosis.
Fig. 30.4 Rectosigmoid cancer invading the bladder (Courtesy of
Philip Y. Pearson, MD)
Fig. 30.5 Endometriosis implants on the small bowel and cecum
It is not uncommon to be asked to evaluate a lesion that
cannot be differentiated from bowel malignancy.
Endometriosis can appear as small, pigmented peritoneal
nodules or fi rm fi brotic masses of the bowel that mimic cancer (Fig. 30.5 ). It rarely invades into the mucosa, but can
present as a partial obstruction due to mass effect or scarring. It has been shown that aggressive management of gastrointestinal endometriosis is safe and produces good
long-term outcomes for patients in terms of reduction of
symptoms and ability to conceive [ 17 ]. Our recommended
approach is to attempt to resect all visible and palpable disease. This is typically done in conjunction with the gynecologist who will manage the ovarian and peritoneal
implants. Bowel involvement can be managed with either
disc excision or segmental resection. Unless the peritoneal
implants on the bowel are very small and superfi cial, we do
not favor partial-thickness excision. The technique is frequently bloody and may leave disease behind. For extensive
cul-de-sac disease, low anterior resection can be performed
safely [
17 ]. Smaller rectal lesions may be removed by disc
470
H.R. Bailey and T.C. Isaacson
Fig. 30.6 Meckel’s diverticulum (Courtesy of W. Brian Sweeney, MD)
excision with transverse closure of the rectal wall.
Depending on the expertise of the consulting gynecologist,
if the disease is extensive, biopsy of a lesion may be taken
and a referral made to a gynecologist with greater expertise
in endometriosis. Treatment may involve medical therapy in
combination with further elective surgery [ 18 ].
the potential of making the bleeding worse. This is a situation where packing and appropriate preparation of the operative team is a crucial fi rst step. Once blood products are
available and the operative and anesthesia teams are prepared and perhaps the incision are enlarged to improve exposure, slow removal of the packs will allow for visualization
of the area in question. Sterile thumbtacks have been shown
to be an effective method to control bleeding. These are
pushed through the usually thin bony table of the sacrum
directly over the site of bleeding. Muscle “welding” has also
been shown in small case series to be a safe, readily available, and highly effective technique. This method involves
taking a 2 × 2 cm piece of free rectus muscle and compressing it against the area of sacral bleeding with a forceps.
Electrocautery is then applied to the muscle to create a coagulum that occludes the venous bleeding [ 21 , 22 ]. Several
new hemostatic agents are also available. In cases of massive
ongoing bleeding, packing the pelvis and transferring the
patient to an ICU for correction of coagulopathy can be an
invaluable maneuver. Re-exploration 24–48 h later usually
reveals that the bleeding has ceased.
Ischemic Bowel
Meckel’s Diverticulum
Key concept: While debatable, resection of a Meckel’s diverticulum is often warranted.
Although the prevalence of a Meckel’s diverticulum has
been shown to be lower than originally thought, at just
1.23 %, the surgical management of this often incidental
fi nding has recently been challenged [ 19 ]. The fi ndings asso-
ciated with a diverticulum can range from an asymptomatic,
incidental discovery to that of bleeding, obstruction, and
even tumor involving the diverticulum (Fig. 30.6 ). The most
recent literature supports its removal as it has been shown
that the incidence of ileal cancer is higher in patients with a
Meckel’s diverticulum than in those who do not have a diverticulum [ 20 ].
Presacral Bleeding
Key concept: You should be familiar with several methods to
aid in hemostasis for severe pelvic bleeding.
This situation may be one that you also encounter in your
own patients. Presacral bleeding can be life threatening and
lead to substantial morbidity if measures are not taken to
quickly and effectively manage the situation. Several techniques exist to help with hemostasis, but the more commonly
employed methods of electrocautery and suture ligation have
Key concept: Clinical evaluation and adjunctive tests aid in
assessing the viability of bowel to determine if resection is
warranted.
During the course of diffi cult dissection, a blood vessel
feeding the bowel may be injured requiring ligation for control. You may be called to evaluate the viability of a segment
of bowel and give your opinion on management. Initial evaluation should include looking at the color of the serosal surface, the presence of bowel peristalsis, and pulsation or
bleeding from the marginal arteries. These observations can
often be misleading, and other methods to determine if resection is in order and how much to resect may be needed.
Additional techniques described include the use of fl uorescence or Doppler ultrasound. Fluorescence encompasses two
techniques, that of perfusion fl uorometry and laser fl uorescence angiography (LFA). Both involve injecting sodium
fl uorescein or indocyanine green intravenously and then
evaluating the bowel with either a Wood’s lamp or laser
light. A single study reports that the use of intraoperative
LFA reduced the risk of revision due to anastomotic leakage
by 60 % in patients undergoing elective colorectal surgery
regardless of their age (and by 64 % in patients above the age
of 70) [ 23 ]. The technique is, however, not widely available.
We have no personal experience with LFA. The use of
Doppler ultrasound to detect signals on the antimesenteric
portion of the bowel can be helpful. Doppler ultrasound was
evaluated in a recent series of 200 patients undergoing
colorectal resections and showed only 1 % incidence of