Oral antibiotic prophylaxis was advised over the past three decades to reduce the infectious complications following colonic surgery. The usual regimen was a combination of oral erythromycin and neomycin taken the day before surgery. Many surgeons would substitute oral metronidazole for erythromycin because patients tolerate it better. With the use of perioperative parental antibiotics, the benefit of oral antibiotics is questioned and most surgeons abandoned the use of oral antibiotics in favor of perioperative parenteral antibiotics.
Ileus Following open abdominal or pelvic surgery, most patients experience some degree of intestinal ileus. The exact mechanism by which this arrest and disorganization of gastrointestinal motility occurs is unknown, but it appears to be associated with the opening of the peritoneal cavity and is aggravated by manipulation of the intestinal tract and prolonged surgical procedures. Infection, peritonitis, and electrolyte disturbances may result in ileus. For most patients undergoing common gynecologic operations, the degree of ileus is minimal, and gastrointestinal function returns relatively rapidly, allowing the resumption of oral intake within a few days of surgery. Patients who have persistently diminished bowel sounds, abdominal distention, and nausea and vomiting require further evaluation and more aggressive management. Patients with symptoms of ileus or small bowel obstruction who underwent minimally invasive surgery are a different matter. Minimally invasive surgery should result in a daily improvement in GI function. An “ileus” in the case of minimally invasive surgery more likely represents GI injury, which should be evaluated immediately with a CT scan using GI contrast.
Ileus is usually manifested by abdominal distention and should be evaluated by physical examination. Pertinent points of the abdominal examination include assessment of the quality of bowel sounds and palpation in search of distension, masses, tenderness, or rebound. The possibility that the patient’s signs and symptoms may be associated with a more serious intestinal obstruction or intestinal complication (such as a perforation) must be considered. Pelvic examination should be performed to evaluate the possibility of a pelvic abscess or hematoma that may contribute to the ileus. Abdominal radiography to evaluate the abdomen in the ﬂat (supine) position and in the upright position will aid in the diagnosis of an ileus. The most common radiographic findings include dilated loops of small and large bowel and air-ﬂuid levels while the patient is in the upright position. Sometimes, massive dilation of the colon or stomach may be noted. The remote possibility of distal colonic obstruction suggested by a dilated cecum should be excluded by rectal examination, proctosigmoidoscopy, colonoscopy, or barium enema. In the postoperative gynecology patient, especially in the upright position, the abdominal x-ray may show free air. This common finding following surgery lasts 7 to 10 days in some instances and is not indicative of a perforated viscus in most patients.
The initial management of a postoperative ileus is aimed at gastrointestinal tract decompression and maintenance of appropriate intravenous replacement ﬂuids and electrolytes.
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The patient should be made NPO status (nothing by mouth) with intravenous (IV) ﬂuids and electrolytes. If nausea and vomiting persist, a nasogastric tube should be used to evacuate the stomach of its ﬂuid and gaseous contents. Continued nasogastric suction removes swallowed air, which is the most common source of gas in the small bowel.
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