Improved Outcomes in Colon and Rectal Surgery part 7. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | improved outcomes in colon and rectal surgery A more difficult or dense adhesion can be approached from different angles to help define the appropriate plane. Oftentimes simpler adhesions can be taken down on either side or even behind the dense adhesion to help delineate the proper path of dissection. Placing one s fingers on either side of the adhesion and palpating can be of assistance to feel the plane and also sometimes stretch out the adhesion for easier division. Of course one of the biggest keys to success is proper traction and counter-traction. If the traction is too forceful though tearing of the bowel may occur. If an enterotomy does occur it should be repaired immediately with absorbable sutures to minimize contamination. If the case is difficult and more injuries are predicted temporary closure can be employed until all adhesiolysis is complete. A segment of bowel with extensive injuries may be best resected. Waiting until all injuries have been identified and a plan made can save significant time on unnecessary repairs. Sometimes dissection can be performed in an extraperitoneal plane to avoid bowel injury leaving peritoneum adherent to the bowel wall. Other times a small piece of bowel wall may be left behind adherent to a more critical structure such as the ureter or iliac vessels in order to avoid morbid injury at these crucial sites. Leaving devascularized bowel serosa or muscularis in-situ is not a problem. Any mucosa left behind however should be desiccated with electrocautery to prevent formation of mucoceles or malignancy. Consideration should be given in each case to preventing adhesions which lowers the risk of bowel obstruction and makes any future surgeries easier. Adhesion formation is a local response of the peritoneum and pertonealized structures to ischemia desiccation or trauma and may form as result of the primary disease process or due to contact with surgical instruments staples suture gloves sponges and other irritants introduced
