Emergency Surgical Care in Gandhinagar & Ahmedabad | Niraaya Hospital

Intestinal perforation is a breach in the full-thickness wall of any part of the gastrointestinal tract - allowing the bowel lumen contents (intestinal bacteria, digestive enzymes, faecal matter) to contaminate the sterile peritoneal cavity. The result is peritonitis - chemical and then bacterial inflammation of the peritoneum - which, if untreated, progresses to generalised sepsis, multi-organ failure, and death.

Causes of intestinal perforation:

Perforated peptic ulcer (stomach or duodenum): The most common cause of small bowel perforation in India. Sudden, catastrophic onset of generalised abdominal pain. Erect CXR or CT shows free air under the diaphragm. Emergency laparoscopic peritoneal lavage and Graham patch closure (suture closure of the perforation reinforced with an omental patch) is performed within hours of diagnosis. Post-operative IV antibiotics, IV proton pump inhibitor therapy, and H. pylori eradication (once the patient recovers) are given.

Typhoid perforation: Ileal perforation from typhoid fever - caused by Salmonella typhi invading Peyer's patches in the terminal ileum, causing transmural necrosis and perforation. Presents in the second or third week of typhoid fever with sudden abdominal pain and guarding. Requires emergency laparotomy - the perforation is closed primarily (if single, small, and surrounded by healthy bowel) or the perforated segment is resected with ileostomy (if multiple, large, or extensively diseased bowel). Mortality remains significant despite timely surgery, primarily from pre-operative delay and associated systemic illness.

Diverticular perforation: As described in the Colon and Rectal Disorders section. Hinchey III (purulent peritonitis) and Hinchey IV (faecal peritonitis) require emergency laparotomy with Hartmann's procedure - sigmoid resection, rectal stump closure, and end colostomy.

Traumatic bowel perforation: Penetrating abdominal trauma (knife wounds, gunshot wounds) and blunt abdominal trauma (road traffic accident - typically injuring the bowel at fixed points - ligament of Treitz, ileocaecal junction) cause intestinal perforation requiring emergency laparotomy and bowel repair or resection.

Iatrogenic perforation: Colonoscopic perforation (a rare but serious complication of diagnostic or therapeutic colonoscopy) - managed with laparoscopic repair when recognised early and the patient is haemodynamically stable.

Intestinal obstruction is the blockage of the passage of intestinal contents - gas, fluid, and stool - through the bowel. It is classified as:

Small Bowel Obstruction (SBO):

The most common cause in adults is adhesions - fibrous bands of scar tissue from previous abdominal surgery that kink or compress loops of small bowel. Other causes include hernias (external herniation with strangulation), internal hernias, tumours, Crohn's disease strictures, and volvulus (twisting). Presents with: colicky central abdominal pain (as the bowel attempts peristalsis against the obstruction), vomiting (bilious in high obstruction, faeculent in distal obstruction), abdominal distension (most marked in distal SBO), and absolute constipation (inability to pass gas or stool).

Simple (non-strangulated) SBO from adhesions is initially managed non-operatively - nasogastric tube decompression, IV fluids, and close monitoring for 24-48 hours. If the obstruction fails to resolve or signs of strangulation develop (fever, tachycardia, severe localised tenderness, metabolic acidosis on blood gas), emergency laparoscopic adhesiolysis or laparotomy with bowel resection (if strangulation has caused necrosis) is undertaken.

Large Bowel Obstruction (LBO):

Most commonly caused by colorectal cancer (60%) in India, followed by acute sigmoid volvulus (twisting of the sigmoid colon - presenting dramatically with massive abdominal distension, absolute constipation, and a characteristic "coffee bean" sign on plain X-ray), and colonic pseudo-obstruction (Ogilvie syndrome - colonic distension without mechanical obstruction, seen in hospitalised patients after surgery or other systemic illness).

Emergency management depends on the cause: sigmoid volvulus is first managed with rigid sigmoidoscopy and flatus tube derotation (successful in 70-80%), followed by elective sigmoid colectomy. Obstructing colorectal cancer requires emergency surgery - colonic stenting as a bridge to surgery in selected cases, or emergency Hartmann's procedure. Dr. Patel performs emergency stenting and surgical management for obstructing colorectal cancer at Niraaya Hospital, Gandhinagar.

Road traffic accidents - the leading cause of trauma in India - cause blunt abdominal trauma through deceleration forces, compression, and direct impact. The spleen, liver, and kidneys are the most commonly injured solid organs; the bowel is injured at fixed anatomical points.

Primary survey and resuscitation: Following the ATLS (Advanced Trauma Life Support) protocol - airway, breathing, circulation, disability, exposure - the trauma patient is rapidly assessed and resuscitated simultaneously. IV access, fluid resuscitation, blood transfusion, and urgent imaging (FAST ultrasound - Focused Assessment with Sonography in Trauma - at the bedside to detect free fluid, followed by CT with IV contrast for haemodynamically stable patients) are performed in rapid sequence.

Indications for emergency laparotomy:

• Haemodynamically unstable patient with free fluid in the abdomen on FAST (indicating haemorrhage from solid organ or mesenteric injury)
• Penetrating abdominal trauma with evisceration, peritonitis, or haemodynamic instability
• Free air on imaging (indicating bowel perforation)
• Failure of non-operative management of solid organ injury

Damage Control Surgery (DCS):

In the most severely injured patients (haemorrhagic shock, coagulopathy, hypothermia, acidosis - the "lethal triad"), abbreviated emergency surgery (controlling haemorrhage and contamination only, packing the abdomen, temporary abdominal closure) is performed first. Definitive repair is planned after 24-48 hours of intensive resuscitation in ICU - when coagulopathy and acidosis have been corrected and the patient is physiologically stabilised.

Dr. Neel Patel manages abdominal trauma with ATLS-aligned protocols at Niraaya Hospital, Gandhinagar - providing immediate emergency surgical care and co-ordinating ICU support for severely injured patients.