Fluid and electrolyte replacement must be adequate to keep the patient well hydrated and in metabolic balance. Significant amounts of third-space ﬂuid loss occur in the bowel wall, the bowel lumen, and the peritoneal cavity during the acute episode. Gastrointestinal ﬂuid losses from the stomach may lead to metabolic alkalosis and depletion of other electrolytes as well. Careful monitoring of serum chemistry levels and appropriate replacement are necessary.
3.
Most cases of severe ileus begin to improve over a period of several days. This improvement is recognizable by a reduction in the abdominal distention, return of normal bowel sounds, and passage of ﬂatus or stool. Repeat abdominal radiographs should be obtained as necessary for further monitoring.
4.
When the gastrointestinal tract function appears to have returned to normal, the nasogastric tube may be removed and a liquid diet instituted.
5.
If a patient shows no evidence of improvement during the first 48 to 72 hours of medical management, other causes of ileus should be sought. Such cases may include ureteral injury, peritonitis from pelvic infection, unrecognized gastrointestinal tract injury with peritoneal spill, or ﬂuid and electrolyte abnormalities such as hypokalemia. With persistent ileus, the use of water-soluble upper gastrointestinal contrast studies (CT scan with oral contrast) may assist in the resolution, but prospective randomized data regarding this maneuver are lacking.
Small Bowel Obstruction Obstruction of the small bowel following major gynecologic surgery occurs in approximately 1% to 2% of patients (123). The most common cause of small bowel obstruction is adhesions to the operative site. If the small bowel becomes adherent in a twisted position, partial or complete obstruction may result from distention, ileus, or bowel wall edema. Less common causes of postoperative small bowel obstruction include entrapment of the small bowel into an incisional hernia and an unrecognized defect in the small bowel or large bowel mesentery. Early in its clinical course, a postoperative small bowel obstruction may exhibit signs and symptoms identical to those of ileus. Initial conservative management as outlined for the treatment of ileus is appropriate. Because of the potential for mesenteric vascular occlusion and resulting ischemia or perforation, worsening symptoms of abdominal pain, progressive distention, fever, leukocytosis, or acidosis should be evaluated carefully because immediate surgery may be required.
In most cases of small bowel obstruction following gynecologic surgery, the obstruction is only partial and the symptoms usually resolve with conservative management.
1.
Further evaluation after several days of conservative management may be necessary. Evaluation of the gastrointestinal tract with barium enema, an upper gastrointestinal study, or a CT scan with small bowel assessment is appropriate. In most cases, complete obstruction is not documented, although a narrowing (“transition point”) or tethering of the segment of small bowel may indicate the site of the problem.
2.
Further conservative management with nasogastric decompression and intravenous ﬂuid replacement may allow time for bowel wall edema or torsion of the mesentery to resolve.
3.
If resolution is prolonged and the patient’s nutritional status is marginal, the use of TPN may be necessary.
4.
Conservative medical management of postoperative small bowel obstruction usually results in complete resolution. If persistent evidence of small bowel obstruction remains after full evaluation and an adequate trial of medical management, exploratory laparotomy may be necessary to manage the obstruction. In most cases, lysis of adhesions is all that is required, although a segment of small bowel that is badly damaged or extensively sclerosed from adhesions may require resection and reanastomosis.