Also examine the mesentery to exclude vascular compromise to the bowel wall.
Repair perforations immediately to limit contamination of the peritoneal cavity. Prior to closure, inspect wound edges for devitalized tissue and, if found, promptly debride it.
If colotomy occurs in the setting of an unprepared bowel with significant spillage, follow closure with copious irrigation.
Small perforations can usually be closed in 2 layers, with an inner layer of 3-0 delayed synthetic absorbable suture (Dexon, Vicryl) through the full thickness of the bowel wall, ensuring mucosal approximation. It is vital that this layer be “waterproof,” allowing no leakage of intestinal contents. Then place a second row of suture in the seromuscular layer using 4-0 silk to imbricate the first suture line.
General surgical consultation is needed whenever the gynecologist is inexperienced with bowel resection and anastomosis.
It also is essential that the suture line be perpendicular to the long axis of the bowel, rather than parallel; otherwise, the bowel lumen would narrow. Even perforations extending along the longitudinal axis for several centimeters should be repaired in transverse fashion to provide a lumen of adequate diameter.
Resecting the small bowel: If inexperienced, obtain general surgery consultation
Bowel resection and anastomosis require a greater degree of skill than is attained in a typical gynecologic training program. For that reason, resection is addressed here only superficially. Our primary caveat: A general surgical consultation should be obtained whenever the gynecologist is inexperienced with bowel resection and anastomosis.
Indications for resection. Strongly consider resection and anastomosis if the perforation involves more than 50% of the circumference of the bowel wall, if multiple perforations occur in a short segment of bowel, or if there is vascular compromise to a segment of bowel. Adequate perfusion to the bowel usually is indicated by a pink serosal surface. If the serosa remains dark or dusky and fails to become pink after several minutes of observation, vascular compromise is likely and resection is preferred.
If there is doubt about the blood supply to the bowel, give 1 g fluorescein intravenously and inspect the bowel under ultraviolet light (Wood’s lamp). Normal vascularized bowel will have a homogenous yellow-green appearance. Patchy fluorescence or areas without any fluorescence are evidence of ischemia.
To drain or not to drain
Because perforation and resection both involve entry into the bowel lumen, some degree of spillage is inevitable. This is of greater concern when the large bowel is involved, because of the increased likelihood of bacterial contamination. Immediate copious irrigation of the peritoneal cavity is indicated. Also consider a pelvic drain, especially when dissection has been extensive or raw surfaces are oozing.
The combination of bacterial contamination and free peritoneal blood in the pelvis increases the risk for infection. A strategically placed, half-inch Jackson Pratt drain (or a similar device) may help prevent abscess. In the event of anastomotic leakage, a drain often allows for a controlled enterocutaneous fistula to be managed without reoperation.
Some surgeons have satisfactory results without these drainage techniques.
When to begin postop feeding: Depends on type of repair
Opinion varies about the appropriate time to commence feeding after major abdominal surgery, particularly bowel surgery. Over the past decade, with the pressure to discharge patients earlier, many physicians have opted for earlier timing.
Traditionally, feeding was withheld until bowel sounds were auscultated; then it progressed slowly. Today many surgeons advance the diet much more quickly, with little or no delay in recovery. Fanning and Andrews9 demonstrated that early feeding does not increase the incidence of anastomotic leakage, dehiscence, or aspiration pneumonia—although it is associated with increased emesis.
Patients undergoing surgery for relatively minor injuries can have their diet advanced as if there were no intestinal involvement.
Feeding after minor repairs. When the surgery has involved relatively minor injuries, such as isolated serosal tears and adhesiolysis, nasogastric tube placement is not required. These patients can have their diet advanced as if there were no intestinal involvement. Give clear liquids when bowel sounds are heard and, if tolerated, advance to solids. It is probably not necessary to await a bowel movement before discharging the patient; she can be released once flatus is passed.
Substantial repairs. When major injuries have been repaired, such as with a large perforation repair or bowel resection, it is prudent to proceed more slowly.
Place a nasogastric tube to minimize bowel distention and subsequent leakage from the repair site. Give the patient nothing by mouth until bowel sounds are clearly present and flatus is passed. Then clamp the nasogastric tube for 24 hours, remove it, and institute clear liquids, provided there is no nausea, vomiting, or distension. Advance to full liquids and then solids, tailoring this process to the patient. When she can tolerate a regular diet, with substantial passage of flatus or bowel movement, recovery is signaled.