Small intestinal obstruction.

Small intestinal obstruction remains a frequently encountered problem in abdominal surgery. Although modern day surgical management continues to focus appropriately on avoiding operative delay whenever surgery is indicated, not every patient is always best served by immediate operation. Certain entities, such as SBO secondary to incarcerated abdominal wall hernia, and patients with clinical signs and symptoms suggestive of strangulation do require prompt operative intervention. Other conditions, however, such as postoperative adhesions and neoplastic-associated SBO, particularly in patients with numerous previous abdominal procedures, concomitant medical problems, or incomplete or partial obstruction, often justifiably benefit by a trial of nonoperative management. The risk of strangulation with adhesive and neoplastic SBO is relatively low as compared with incarcerated hernia and small bowel volvulus. Close and careful clinical evaluation, in conjunction with laboratory and radiologic studies, will usually dictate the proper course of management in any given case. If any uncertainty exists, prompt operative intervention is indicated. Because over 50 per cent of all cases of SBO are the direct result of postoperative adhesions, it is probably just as important as the actual management of SBO for all practicing abdominal surgeon to familiarize themselves with the widely accepted "ischemic theory" of adhesion formation. A number of intraoperative measures, many of which go against established surgical principles, are now encouraged during routine elective abdominal surgery to reduce the incidence of detrimental adhesions that might subsequently produce SBO. At the same time, surgeons should continue their aggressive attitude towards elective repair of any and all abdominal hernias, which continue to account for close to 15 per cent of all cases of small intestinal obstruction and still remain the most common cause of strangulation.