Adhesive small bowel obstruction (ASBO) is a common postoperative complication and remains a leading cause of emergency surgical admissions. This review synthesizes current evidence regarding the diagnosis, conservative management, and surgical treatment of ASBO, focusing on the role of standardized protocols in optimizing patient outcomes. ASBO most often develops following abdominal or pelvic surgery, especially after open procedures. Conservative management, including nasogastric decompression, water-soluble contrast studies (e.g., Gastrografin), and nutritional support, is effective in 65% to 80% of cases without ischemia or strangulation. However, fever, leukocytosis, persistent pain, or computed tomographic findings (e.g., the whirl sign or bowel wall thickening) necessitate early surgical intervention. Evidence indicates that extending conservative management beyond 3 to 5 days in nonresponders increases both morbidity and mortality. Recent studies do not support routine antibiotic or antispasmodic use in uncomplicated ASBO. Although analgesics and ambulation may provide symptom relief, their impact on surgical timing remains unclear. Laparoscopic adhesiolysis has demonstrated reduced morbidity and shorter hospital stays versus open surgery in appropriately selected patients. Accurate differentiation between ASBO and postoperative ileus is essential for effective treatment. Conservative management remains the first-line approach in cases of partial ASBO, but clinicians must be vigilant for signs of clinical deterioration. Surgical management, including laparoscopic intervention, should be promptly pursued if conservative therapy fails or patients exhibit clinical decline. Implementing evidence-based guidelines and individualized decision-making improves patient safety, reduces complications, and enhances overall outcomes. Ongoing research is needed to refine conservative strategies and identify predictive markers for early surgical intervention.

A 51-year-old female underwent recurrent open incisional hernia repair with retrorectus mesh placement. Early in the post-operative course, she developed a hernia reoccurrence secondary to breakdown of the staple line, at the level of the posterior rectus sheath, resulting in a small bowel obstruction. This hernia could not be felt upon physical examination but was detected by imaging. The patient was promptly taken to the operating room for laparoscopic reduction of the incarcerated loop of small intestine, along with laparoscopic repair of the posterior rectus sheath defect. It is critical for surgeons to recognize the possibility of a staple line breakdown at the level of posterior rectus sheath early on in the diagnosis which would prompt urgent surgical intervention in the setting of a bowel obstruction.

Citations

• Strangulated interstitial interparietal hernia following lower segment caesarean section: a case report
  Celine Garrett, Ruwanthi Wijayawardana, David L Morris
  Journal of Surgical Case Reports.2023;[Epub]     CrossRef

Purpose
Phytobezoar is the most common type of bezoar, which can occasionally present as an intestinal obstruction. In this study, the surgical experience and outcome in the management of intestinal obstruction caused by bezoars are described.
Methods
A retrospective analysis of all operative cases of bezoars (n = 36) at Khoo Tech Puat hospital between 2011–2017 was performed. Patient demographics, imaging and operative findings, characteristics of bezoars and related morbidities were analyzed. The study population was subdivided into 2 groups based on operative intervention (fragmentation and milking of bezoars, versus enterotomy and/or bowel resection).
Results
There were 36 cases of bezoars in 35 patients that were included in this study. Computed tomography scans were diagnostic of bezoars in 27 cases (75%). There were 20 cases (55.6%) that underwent fragmentation and milking of bezoars. The remaining 16 cases (44.4%) required an enterotomy or bowel resection. Bezoars that required enterotomy / bowel resection were more likely to be distally located in the ileum (75% vs 40%, p = 0.01), larger in volume (86.5 mL vs 63 mL, p = 0.04), with significant increase in morbidity rates (43.8% vs 5%, p < 0.01) compared with all other cases of bezoars.
Conclusion
Risk factors for enterotomy / bowel resection in bezoar bowel obstruction include, nondiagnostic computed tomography scans, distally located, and larger volumes of bezoars. Fragmentation and milking should be attempted first as it has lower morbidity rates than enterotomy / bowel resection surgery.

Citations

• Combined transnasal ileus tube and colonoscopy to treat a giant fecalith-caused small bowel obstruction
  An Ren, Jia-Chong Li, Xiang-Fu zeng, Shu-feng Zhao
  Asian Journal of Surgery.2025; 48(3): 1837.     CrossRef
• Colon obstruction due to sunflower seed bezoar: A case report
  Seyedeh Mahdieh Khoshnazar, Omid Eslami
  International Journal of Surgery Case Reports.2025; 128: 110841.     CrossRef
• Evaluation of the location, number and diameter of bezoars in patients with a history of previous gastrointestinal surgery
  Ali Muhtaroğlu, Merve Yiğit, Hakan Demir, Uğur Dülger, Muhammed Doğangün, İbrahim Furkan Küçük, Fatih Altintoprak
  European Journal of Trauma and Emergency Surgery.2023; 49(4): 1783.     CrossRef
• The Role of Non-Contrast CT in the Diagnosis of a Rare Cause of Small Bowel Obstruction Due to Bezoar
  Ai Jiun Koa, Yong Sim Teh
  Malaysian Journal of Medicine and Health Sciences.2023; 19(2): 334.     CrossRef
• Phytobezoar-Induced Mechanical Ileus and Incipient Intussusception: A Case Report
  Christoforos S. Kosmidis, Chrysi Maria Mystakidou, Nikolaos Varsamis, Charilaos Koulouris, Christina Sevva, Konstantina Papadopoulou, Christina Michael, Nikolaos Iason Katsios, Vasiliki Theodorou, Petrina Miltiadous, Konstantinos Papadopoulos, Konstantino
  Medicina.2023; 59(7): 1227.     CrossRef
• Small bowel obstruction secondary to phytobezoar in a patient with myotonic dystrophy
  Nicholas L Harrison, Giovanni Santoro, Nicolas Ellerby, Ajai Samad
  BMJ Case Reports.2023; 16(10): e255895.     CrossRef
• Bezoar-induced small bowel obstruction: a rare cause of a common problem
  Evan Gorgas, Shawn Dowling
  Journal of Surgical Case Reports.2023;[Epub]     CrossRef

Purpose:

Open adhesiolysis has been the favored approach regarding surgical management of intestinal obstruction. Following the development of laparoscopic devices and necessary surgical techniques, laparoscopic treatment of intestinal obstruction and adhesion has been tried in highly selected cases. Our study was designed to investigate laparoscopic adhesiolysis to treat intestinal obstruction.

Methods:

The clinicopathologic data and surgical outcomes of 14 patients who underwent emergency laparoscopy between January 2007 and April 2015 were retrospectively reviewed.

Results:

Five patients had a history of abdominal surgery, and twelve patients had adhesive intestinal obstruction. The causes of adhesive intestinal obstruction included tuberculous peritonitis, periappendiceal abscess, serosal fibrosis and chronic inflammation of intestine, gastric volvulus by fibrotic band. Two patients had non-adhesive intestinal obstruction, caused by intussusception and small bowel ulcer with stricture. The mean surgical time was 98.5 minutes, with mean blood loss of 35 ml. One case was converted to open surgery (7.1%). The mean postoperative hospital stay was 6.5 days. The mean time to oral intake was 3.4 days. There were no postoperative complications or deaths.

Conclusion:

When the patients are selected carefully in accordance with the guidelines, in our experience laparoscopic adhesiolysis is safe and feasible.