What are the intraoperative details of surgical resection for lower gastrointestinal (GI) bleeding?

Updated: Jul 26, 2019
  • Author: Burt Cagir, MD, FACS; Chief Editor: BS Anand, MD  more...
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Answer

Surgical intervention is required in only a small percentage of patients with lower gastrointestinal bleeding. The surgical option depends on whether the bleeding source has been accurately identified preoperatively; if so, it is then possible to perform segmental intestinal resection.

If the bleeding source is unknown, an upper GI endoscopy should be performed before any surgical exploration. At celiotomy, identifying the bleeding point is often impossible, as blood refluxes into the proximal and distal bowel.

The abdominal cavity is explored through a midline vertical incision. The assistance of a gastroenterologist or another surgical endoscopist or surgeon is required for intraoperative endoscopic evaluation. The colonoscope is introduced, and the surgeon assists its passage. On-table colonic lavage and colonoscopy may identify the colonic source of bleeding. Surgeon-guided intraoperative small bowel enteroscopy is also performed when no colonic source of bleeding is identified. Again, the colonoscope can be used for this procedure.

Unlike colonoscopy, enteroscopy is performed during the advancement of the scope. Colonoscopic manipulation of the small bowel may cause iatrogenic mucosal tears and hematomas, which may be mistakenly identified as a source of bleeding. Another intraoperative strategy is to clamp segments of the bowel with noncrushing intestinal clamps to identify the segment that fills with blood. If the bleeding point cannot be diagnosed through intraoperative pan-intestinal endoscopy and examination, and if evidence points to a colonic bleeding, perform a subtotal colectomy with end ileostomy.


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