This protocol addresses adhesive small bowel obstruction (ASBO) in patients without peritonitis, without strangulation, and without bowel ischemia — specifically in the situation where a structured trial of non-operative management has run its course without achieving resolution.
Non-operative management is the appropriate first step in all patients with ASBO when there are no signs of peritonitis, strangulation, or bowel ischemia. This protocol is reached when that conservative trial does not lead to obstruction resolution.
Previous line: Non-operative management — nil per os, intravenous fluid resuscitation with fluid and electrolyte supplementation, correction of electrolyte disturbances, decompression via nasogastric or long intestinal tube, and nutritional support — was continued for up to 72 hours.
Failure criterion not met: Resolution of bowel obstruction, indicated by progression of water-soluble contrast reaching the colon on abdominal X-ray taken 24 hours after administration, was not achieved. This unmet criterion is the trigger for operative intervention.
When operative treatment is required, the primary approach is open surgical exploration — laparotomy with adhesiolysis. In selected cases of simple ASBO, a laparoscopic approach may be considered where sufficient experience is available; specific clinical factors determine which patients are appropriate candidates for this approach.
The complete operative criteria, patient selection algorithm, and stepwise protocol are available via the link below.
DOI: 10.1186/s13017-018-0185-2
Non-operative management should always be tried in patients with adhesive small bowel obstruction, unless there are signs of peritonitis, strangulation, or bowel ischemia.
The panel recommends a trial of non-operative management in all patients with ASBO, unless there are signs of peritonitis, strangulation, or bowel ischemia.
When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.
Farinella et al. reported that predictors for a successful laparoscopic treatment of ASBO are the following: ≤ 2 laparotomies in history, appendectomy as the operation in history, no previous median laparotomy incision, and a single adhesive band.
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