Critical operative management of small bowel obstruction.

The records of 238 patients with the diagnosis of small bowel obstruction at the University of Illinois Hospital from 1967 through the spring of 1976 were reviewed. Mortality, intra-operative management, and clinical findings were evaluated. Previous reports list a mortality of gangrenous small bowel obstruction, secondary to hernia and/or adhesions, as greater than 20%, although in this series, the mortality was 4.5% in patients with gangrenous small bowel obstruction. The present data reveal a 60% incidence of wound infection in patients in whom an enterotomy (iatrogenic, decompressive or resective) was made and the subcutaneous tissue and skin closed, and it is therefore recommended that the wound be left open in these situations. Although a variety of individual clinical findings have been advocated as diagnostic aids in patients with small bowel obstruction, this review suggests that attention to a combination of "classic" findings, i.e., leukocytosis, fever, tachycardia and localized tenderness, portends a situation in which conservative observation is safe--namely, the absence of all four findings. The presence of any one or more of these findings mandates early operative intervention.