Is it advisable to proceed with initial excision without a colorectal surgeon present for a patient with a history of bowel adhesions and suspected bowel involvement, who is experiencing debilitating pain while waiting for multidisciplinary surgical team availability?

Staged Surgery is Not Advisable - Proceed Only with Multidisciplinary Team Present

For a patient with suspected bowel involvement and history of bowel adhesions experiencing debilitating pain, you should NOT proceed with initial excision without a colorectal surgeon present, as this approach risks incomplete resection, bowel injury during adhesiolysis, and the need for emergent unplanned bowel surgery under suboptimal conditions. 1

Why Staged Surgery is Problematic in This Context

Risk of Intraoperative Bowel Injury

• Adhesiolysis in patients with extensive adhesions carries a 6.3-26.9% risk of enterotomy during surgical intervention 1
• Bowel injuries may not be immediately recognized intraoperatively, leading to delayed diagnosis of perforations with severe consequences 1
• Without a colorectal surgeon present, management of unexpected bowel complications becomes suboptimal and may require damage control techniques 1

Incomplete Disease Management

• If bowel involvement is confirmed intraoperatively without appropriate surgical expertise present, you face three poor options: abort the procedure leaving disease behind, attempt resection without appropriate expertise, or convert to damage control with planned reoperation 1
• Damage control surgery (resection with stapled bowel ends and laparostomy) should be reserved for patients with severe sepsis/septic shock, not elective cases 1

Adhesion Reformation After Initial Surgery

• Any abdominal surgery creates new adhesions - performing the initial excision will generate additional adhesive disease 1, 2
• A second operation for bowel surgery will then require adhesiolysis through freshly formed adhesions, increasing the technical difficulty and complication risk 1, 3
• Adhesion barriers (icodextrin 4% solution or hyaluronate-carboxymethylcellulose) can reduce recurrence from 11.11% to 2.19%, but only if applied at the definitive operation 1

The Correct Approach: Optimize and Coordinate

Pain Management While Awaiting Surgery

• Initiate appropriate analgesia with opioids for severe pain, recognizing that opioids themselves can worsen bowel dysmotility but pain control is essential 1
• Consider antiemetics if nausea/vomiting is present 1
• Ensure adequate hydration and electrolyte management 1, 4

Preoperative Optimization

• Nutritional status should be optimized before any surgical procedure in patients with chronic symptoms 1
• Correct any electrolyte abnormalities, anemia, or coagulopathy 1
• Obtain high-quality CT imaging with IV contrast to map the extent of disease and identify bowel involvement, transition points, or signs of obstruction 1, 5

Coordinate Multidisciplinary Team Availability

• Schedule surgery when both gynecologic and colorectal surgeons are simultaneously available 1
• This is not optional - it represents standard of care for suspected bowel involvement 1
• The alternative of staged procedures exposes the patient to multiple anesthetics, increased adhesion formation, and higher cumulative morbidity 1, 2

Common Pitfalls to Avoid

Do not be swayed by patient pressure to "do something now" - explain that proceeding without appropriate surgical expertise present creates higher risk of complications, incomplete treatment, and need for additional operations 1

Do not underestimate the likelihood of bowel involvement - history of bowel adhesions makes intraoperative bowel complications highly probable 1, 3

Do not assume a second operation will be straightforward - fresh postoperative adhesions from the first surgery will complicate the second procedure significantly 1, 2, 6

The patient's debilitating pain is real and deserves aggressive management, but the solution is optimizing pain control and expediting coordinated multidisciplinary surgery, not proceeding with incomplete staged procedures that increase overall risk and morbidity.