A 45-year-old man undergoes surgery for small bowel obstruction from adhesions. Intraoperatively, a 40 cm segment of ischaemic bowel is found with questionable viability. After resection of clearly necrotic bowel, the surgeon is uncertain about the viability of a remaining 30 cm segment. What is the correct damage control decision?

• A Leave the questionable segment, close abdomen temporarily (damage control laparotomy), and plan a second-look laparotomy in 24–48 hours ✓
• B Resect all 30 cm immediately to avoid complications and create primary anastomosis
• C Infuse warm saline over the bowel and if pink after 10 minutes, proceed with primary anastomosis
• D Divide the bowel and bring both ends out as stomas without further assessment

Explanation

In the setting of equivocal bowel viability intraoperatively, the principle of damage control surgery dictates that doubtful bowel should be left in situ with temporary abdominal closure and mandatory second-look laparotomy at 24–48 hours. At the re-look, the bowel is reassessed: clearly viable bowel is anastomosed, clearly necrotic bowel is resected. This approach avoids unnecessary extensive resection causing short bowel syndrome while ensuring necrotic bowel is not left. The Doppler probe and fluorescein dye injection are adjuncts for assessing viability intraoperatively.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.