Causes of SBO

Lesions Extrinsic to the Intestinal Wall

Adhesions (usually postoperative) Hernia
• External (e.g., inguinal, femoral, umbilical, or ventral hernias) 

• Internal (e.g., congenital defects such as paraduodenal, foramen of Winslow, and
diaphragmatic hernias or postoperative secondary to mes- 
enteric defects)
• Neoplastic 
- Carcinomatosis, Extraintestinal neoplasms
• Intra-abdominal abscess 


Lesions Intrinsic to the Intestinal Wall 


- Congenital 
- Malrotation
- 
Crohn’s disease
- Infections 
- Tuberculosis
- Diverticulitis
- 
Neoplasms 

- Traumatic - 
Hematoma
- 
Intussusception

- Foreign body 


Malrotation
- Midgut herniation persists until 10 wks of fetal gestation -> intestines
returns to abd cavity
- Completes a 270 degree rotation (CCW around axis of SMA) -> proximal
jejunum reenters abd and goes to left of abd
- Cecum enters last and located temporarily to RUQ
o With time, descends to normal position in RLQ
- By week 12, colon fixed to retroperitoneum

MC anomaly –duodenojej or cecal limb fails correct rotation

-> results in duodenojej and ileocecal junction that lie close together and midgut
suspended on a narrow SMA stalk
 midgut can twist in CW fashion to get volvulus
- When nonrotation of duodenojej limb -> but cecal limb has normal rotation
o Duodenal obstruction by abnormal bands (LADD BANDS) that extend
from colon across ant duo
o Low risk of volvulus bc broad mesenteric base bw duojej and cecum
o Vs. correct rotation od duojej w/ nonrotation of cecum -> narrow

Presentation
- MC sxs during 1st month of life
o Emergency bc evolving ischemic bowel loops
o Bilious emesis, somnolent newborn
- Can also be incomplete/intermittent volvulus -> chronic abd pain w/ emesis
episodes that are non bilious, early satiety, wt loss
Dx
Upper GI contrast series – abnl position of ligament of treitz
 - bird’s beak in 3rd duo
Rx – Ladd Procedure
- twisted bowel eviscerated
- volvulus untwisted CCW, necrotic segments resected
- can live marginal ischemic segments for 2nd look
- Ladd bands divided (extends from asc colon across duod to posterior aspect
of RUQ
- Cecum mobilized and mesenteric base broadened to prevent recurrent
volvulus
- Incidental appendectomy bc cecum will lie on left side
o Place back bowel SB loops on R and colon in left

Cecal volvulus
- axial rotation of T-ileum, cecum, ascending colon w/ concomitant twisting of
mesentery
- causes: malro, previous surg, preg, left colon obstructing lesion
- sudden abd pain and distention
o early phase: mod pain -> ischemia = incr pain

Lap Entry
1. Closed
a. Blind non-visual entry or visual w/ opti
b. Veress needle – insert into umbilical area in midsagittal plane
i. Can insert in palmer’s point (LUQ, 2cm inf to costal margin in
midclav line)
ii. Blind insertion of trochar after pneumoperitoneum
2. Open/Hasson trochar (previous lap pts)
a. Infra umbilical incision away from midline
b. Retract muscle laterally and slide over post rectus sheath