Webster defines reoperation as an operation to correct a condition not corrected by a previous operation or to correct the complications of a previous operation [1]. For the surgeon, the definition is more personal as it is often perceived as a failure or personal shortcoming. Early re-operative intervention has struck fear in the hearts of surgeons for many years [2]. In emergency surgery, outcomes are significantly worse when relaparotomy is required [3, 4]. Kim et al. [5] showed an overall mortality rate of 9 % in patients undergoing emergency surgery, with an increase to 21 % in patients who required relaparotomy. Timing of re-operation is also fraught with difficulty as re-operative surgery in the more immediate (less than 10 days) and more significantly delayed time periods (after six to eight weeks) is viewed to be less technically difficult as adhesions are thought to be less dense during those time periods [6].

The main questions when approaching a patient who potentially requires a relaparotomy in the delayed postoperative period can be split into the following categories:

In this chapter, we will seek help to guide you through these questions and their potential solutions.

The most important question to answer preoperatively is whether this patient indeed requires another laparotomy or will the cure, operative, or non-operative be worse than the situation at hand. Literature has shown that having ischemic bowel at initial laparotomy or requiring emergent surgery places a patient at a higher risk for both developing an early postoperative bowel obstruction and potentially requiring relaparotomy [5, 7]. Early postoperative bowel obstruction has a greater rate of strangulation and mortality as well as a greater rate of non-adhesive causes such as internal hernia, ischemia, fascial dehiscence, inflammatory reactions, and anastomotic technical failures when compared to more delayed bowel obstructions [8]. Fortunately, over seventy percent of early postoperative small bowel obstructions respond to conservative management with bowel rest, nasogastric suction, and intravenous fluids [9]. However, the time frame over which the bowel obstructions resolve can be quite extensive, ranging from seven to twenty-eight days [10]. Being able to more accurately predict which patient will have a more protracted or unsuccessful course of non-operative management would be quite advantageous. This would allow the surgeon to intervene in an earlier, likely safer, time period and save the patient from an extended time with inadequate nutrition, nasogastric decompression, and a protracted hospitalization. Computed tomography (CT) can be helpful in differentiating those who are more likely to have a complete obstruction, which would mandate more emergent re-operation, from those who have an incomplete obstruction that may resolve with conservative management [11]. Often times in a postoperative patient, however, the CT scan is not always as clear-cut, necessitating other methods of identifying the patient who will require a re-operation. A formal upper gastrointestinal study with small bowel follow through utilizing water-soluble contrast can help differentiate whether the obstruction is functional or mechanical [12]. Another diagnostic and potentially therapeutic intervention that has been gaining ground is a gastrografin challenge as described by Goussous et al., where a patient undergoes nasogastric tube decompression for a short interval with subsequent administration of gastrografin. The presence of contrast in the colon within eight hours or the patient having a bowel movement represents a successful challenge indicating that the obstruction will most likely resolve with non-operative management with a 94 % positive predictive value [13]. The sensitivity of a positive gastrografin challenge predicting resolution of a postoperative bowel obstruction without operative intervention is 98 % with a specificity of 63 % [14]. A negative gastrografin challenge does not have the same predictive quality as a positive challenge as in the early postoperative period a patient with an ileus may have delayed transit, yet resolve without operative intervention. If a patient has a negative gastrografin challenge and if there are no clinical or radiological signs of the obstruction improving after two weeks, the patient should undergo re-exploration as the obstruction is unlikely to resolve with conservative management [8, 14].

For the case above, another dilemma is determining whether the thickened segment of jejunum seen on CT is compromised and beyond salvage or if it will recover over time. Findings on CT that raise concern for bowel ischemia include a thickened bowel wall, mural thumb printing, pneumatosis intestinalis and/or portal venous gas, absence of bowel wall enhancement with intravenous contrast, hazy mesentery, and free fluid [15]. The patient in the scenario above has a segment of thickened bowel, but none of the other pathognomonic findings concern for bowel ischemia. At postoperative day seven could the thickening still just be resolving inflammation from having been ischemic prior to the first operation? Certainly, physical examination findings of localized or generalized peritonitis and serum studies including an elevated white blood cell count or elevated lactate level could help differentiate more simple “postoperative inflammation” from something more sinister.

What about the finding of a “transition point” seen on the CT scan of our patient is that alone enough to mandate repeat laparotomy? In all comers with small bowel obstructions, Suri et al. found that an identifiable transition point on CT was significantly associated with the need for operation in patients with a small bowel obstruction, while both Zielinski et al. and Colon et al. did not. Making the finding of a transition point in our patient is not single handedly predictive of requiring another operation [16–18].

Other common clinical scenarios encountered by acute care surgeons that can necessitate re-operation in the early postoperative period are wound dehiscence (skin and/or fascia), intra-abdominal abscess formation, and anastomotic leaks. Skin dehiscence can often be managed with local debridement and wound care either with dressing changes or in some larger wounds negative pressure wound therapy with a vacuum-assisted dressing management system (KCI, San Antonio, TX). Fascial dehiscence nearly always requires re-operation. It is important however to determine the etiology of the fascial dehiscence (technical error, fascial quality, intra-abdominal cause, etc.) so that it can be addressed in order to prevent recurrence. For a dehiscence caused by a technical error or fascial quality, the only intervention needed may be fascial reclosure. (Please see the intra-operative decision-making and management section for further details on suggestions and pitfalls of re-operative fascial closure.) Any contributing intra-abdominal cause like bowel distension or infection should be addressed prior to reclosure of the fascia.

Advances in minimally invasive percutaneous interventions have greatly decreased the need for open operative drainage of intra-abdominal collections and abscesses [19]. When percutaneous drainage fails, however, operative intervention may be necessary to control the intra-abdominal sepsis [20]. This can be performed laparoscopically or open depending on the clinical situation as well as the skill set of the surgeon. During the abdominal washout, performing as little dissection as is necessary in order to control the septic source and placing drains will help decrease the change of doing further harm.

Anastomotic leaks also require re-intervention. There is a growing body of literature regarding conservative management of controlled leaks with bowel rest and percutaneous intervention [21]. A limited trial of conservative management in a completely non-toxic patient with a truly walled-off collection with no diffuse peritoneal spillage can be considered. The danger with this approach, however, is missing early signs of organ dysfunction and thereby greatly increasing the patient’s risk of developing sepsis and organ failure. For the vast majority of anastomotic leaks, re-operation, either open or laparoscopic, with drainage and most often fecal diversion either with a loop or end ostomy depending on the clinical situation is required [22].

So what should be done with the patient above with a persistent small bowel obstruction and obvious mid-jejunal transition point with a thickened segment of bowel? If she has an elevated lactate, elevated white blood cell count, peritoneal findings or a small bowel follow though study that shows a mechanical obstruction, she should undergo re-operation as her issues are unlikely to resolve with continued conservative management.

Once it is determined that the patient needs to undergo re-exploration the question of when and how comes to the forefront. Ideally, re-exploration is undertaken either prior to postoperative day ten or after six weeks. Often times this is not possible. The re-operative abdominal wall is a challenge in and of itself as repeated operation through an incompletely or minimally healed wound portends potential major complications in the abdominal wall [23]. An abdominal wall that has sustained multiple incisions is more also more likely to have altered vascularity and impaired wound healing leading to a higher risk of poor fascial healing as well as skin and soft tissue infections. Dense adhesions and scar tissue formation within the re-operative abdomen also lead to a higher risk of inadvertent intra-abdominal injuries and postoperative complications that may require yet another surgical procedure to correct [24]. The patient and their family should be counseled regarding the increased complexity and difficulty of a re-operative procedure as well as the prolonged recovery that will likely be encountered compared to a primary procedure.

Advances in imaging techniques, particularly computed tomography, have greatly enhanced not only our ability to make more educated decisions regarding the need for re-operation but have also greatly assisted our ability to preoperatively plan [25]. Prior to proceeding with the re-operation care should be taken to ensure that the patient is adequately resuscitated. Also, the surgeon should ensure that they are well prepared and rested for the procedure as it will likely be challenging and present multiple obstacles and decision points.