Bowel surgery

Last updated: July 6, 2023

Summarytoggle arrow icon

Bowel surgery encompasses all surgical procedures of the small and large intestine. The underlying conditions most commonly requiring bowel surgery are malignancies (especially colorectal cancer) and inflammatory processes (e.g., sigmoid diverticulitis). These surgical procedures may require the creation of an artificial bowel outlet (stoma). Depending on the underlying disease process and the planned surgical procedures, a stoma may be temporary or permanent. A permanent stoma is created following a procedure in which continence could not be preserved, whereas a temporary stoma allows for uninterrupted bowel healing (e.g., following surgery). Intestinal stomas are usually loop stomas, consisting of a proximal and a distal end, while end stomas have one opening which functions as an artificial anus. Major complications of bowel surgery include anastomosis insufficiency, which may lead to abscess formation, peritonitis, and sepsis, and fascial dehiscence, which may lead to organ evisceration and incisional hernias. Common stoma complications include skin irritation and dehydration secondary to high output. Bariatric surgery is an effective treatment for weight loss in patients with obesity and metabolic syndrome. Common complications associated with the procedure include dumping syndrome, strictures, and internal hernias.

Further bowel surgery techniques such as left and right hemicolectomy, transverse colectomy, proctocolectomy, and ileal pouch-anal anastomosis are discussed in the articles on colorectal cancer and ulcerative colitis.

Procedure/applicationtoggle arrow icon

Basic surgical approaches

Bowel surgery can either be performed laparoscopically or as a conventional open procedure. The creation of an artificial bowel outlet or stoma (see below) may be necessary.

Elective surgery

The following factors can help maximize surgical efficacy in planned procedures:

  • Time surgery to take place in periods in which possible inflammation is absent or low.
  • Optimum treatment of comorbid conditions prior to surgery
  • Adequate preoperative measures to prevent abdominal infection (e.g., antibiotic prophylaxis, intestinal cleansing )

Emergency surgery

The acute onset of severe illness requiring emergency surgery typically means that preoperative conditions cannot be optimized (see above). This can considerably increase the risk for intraoperative and postoperative complications.

  • Measures to prevent complications: in a two-stage surgical procedure, a temporary stoma is created in a first step to divert stool from diseased portions of the bowel, allowing rest, and is reversed in a second step after healing has occurred.

Stoma (enterostomy, artificial bowel outlet, artificial anus) [1]

  • Indication: allows removal of feces from the body
  • Procedure
    • The site of the stoma is selected and marked prior to surgery
    • The protruding bowel is secured by a support ring to prevent it from slipping back through the incision.
    • A skin barrier that allows for attaching the collection bag is fitted over and around the stoma.

Loop stoma

End stoma

  • Technique
    • Exteriorization of the proximal end of the bowel. The distal end is sutured or stapled closed and remains as a blind pouch in the abdomen.
    • The bowel is pulled out 1–2 cm and then sutured to the skin.
    • Usually, parts of the colon (colostomy) are used.
  • Indications
  • Handling [2]
    • In colostomy patients, irrigation is an option (controlled evacuation of the bowel to have a period free of output, restoring control)
      • Irrigation involves a lavage of the bowel via the stoma to allow for controlled fecal drainage with subsequent temporary removal of the collection bag and coverage of the stoma with a stoma cap or plug (up to 24–48 hours).
      • This enables the patient to participate in activities (e.g. sports) in which a stoma bag would be inconvenient.
    • In ileostomy, irrigation is pointless, since bowel contents are drained continuously rather than intermittently from the small bowel.
    • Depending on the indications for the initial operation and the underlying condition, re-anastomosis with restoration of intestinal continuity may be possible 3–4 months following surgery.

Fascial dehiscencetoggle arrow icon

Definition [3]

Risk factors [3][4]

Clinical features [3]

  • Most commonly occurs 6–12 days after surgery [3][5]
  • Profuse serosanguinous drainage
  • Possible “popping” or tearing sensation
  • Bulge during Valsalva maneuvers
  • Visibly protruding intestine in complete fascial dehiscence
  • Clinical features of other complications, e.g., intraabdominal infection


Treatment [3][6]

  • Interim management
    • Cover wound with moist dressing.
    • Use adhesive tapes and abdominal binders to prevent further wound dehiscence.
  • Definitive treatment: urgent surgical revision with debridement and reapproximation of the fascial edges


  • Organ evisceration: protrusion of abdominal organs through the outer abdomen
  • Intraabdominal sepsis
  • Incisional hernia

The risk of mortality in fascial dehiscence after laparotomy is up to 35%. [3]

Prevention [3][6]

Anastomosis insufficiencytoggle arrow icon

Definition [3]

Anastomosis insufficiency is a complication that occurs after surgical connection of two luminal structures and leads to luminal content leakage.

Risk factors [8]

Clinical features [3]

Signs of gastrointestinal leak include fever, tachycardia, peritonitis, and feculent or purulent drainage. [10]

Diagnostics [3]

Treatment [3]

Obtain a surgical consult, as treatment depends on the patient's clinical condition and may include:

Ostomy complicationstoggle arrow icon

Risk factors [11]

Early complications [12][13][14]

Late complications [12][14][15]

Bariatric surgerytoggle arrow icon


Procedures [17][18][19]

Bariatric surgery is an effective treatment for obesity and metabolic syndrome; however, clinicians must weigh these benefits against the risks associated with surgery.

Complications [10][21]

Do not attempt nasogastric tube insertion without consulting the surgical team because altered anatomy increases the risk of injury from a blind insertion.

Consider nongastrointestinal etiologies for abdominal pain, such as myocardial infarction, because bariatric patients may have additional comorbidities such as coronary artery disease. [22]

Referencestoggle arrow icon

  1. Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Elsevier ; 2021
  2. van Ramshorst GH, Nieuwenhuizen J, Hop WCJ, et al. Abdominal Wound Dehiscence in Adults: Development and Validation of a Risk Model. World J Surg. 2009; 34 (1): p.20-27.doi: 10.1007/s00268-009-0277-y . | Open in Read by QxMD
  3. Denys A, Monbailliu T, Allaeys M, Berrevoet F, van Ramshorst GH. Management of abdominal wound dehiscence: update of the literature and meta-analysis. Hernia. 2020; 25 (2): p.449-462.doi: 10.1007/s10029-020-02294-4 . | Open in Read by QxMD
  4. Hermawan GN, Wibisono JJ, Nembo LF. Abdominal Wound Dehiscence: A Review of Risk Factors, Prevention and Management in Obstetrics and Gynecology Practice. Medicinus. 2021; 8 (3): p.102.doi: 10.19166/med.v8i3.3767 . | Open in Read by QxMD
  5. Schaaf S, Willms A, Schwab R, et al. Recommendations on postoperative strain and physical labor after abdominal and hernia surgery: an expert survey of attendants of the 41st EHS Annual International Congress of the European Hernia Society. Hernia. 2021; 26 (3): p.727-734.doi: 10.1007/s10029-021-02377-w . | Open in Read by QxMD
  6. $Colostomy guide.
  7. Managing your Colostomy. Updated: January 1, 2016. Accessed: December 12, 2016.
  8. Zarnescu EC, Zarnescu NO, Costea R. Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery. Diagnostics. 2021; 11 (12): p.2382.doi: 10.3390/diagnostics11122382 . | Open in Read by QxMD
  9. Hyman N, Manchester TL, Osler T, et al. Anastomotic Leaks After Intestinal Anastomosis. Ann Surg. 2007; 245 (2): p.254-258.doi: 10.1097/01.sla.0000225083.27182.85 . | Open in Read by QxMD
  10. McCarty TR, Kumar N. Revision Bariatric Procedures and Management of Complications from Bariatric Surgery. Dig Dis Sci. 2022; 67 (5): p.1688-1701.doi: 10.1007/s10620-022-07397-9 . | Open in Read by QxMD
  11. Zelga P, Kluska P, Zelga M, et al. Patient-Related Factors Associated With Stoma and Peristomal Complications Following Fecal Ostomy Surgery. J Wound Ostomy Continence Nurs. 2021; 48 (5): p.415-430.doi: 10.1097/won.0000000000000796 . | Open in Read by QxMD
  12. Babakhanlou R, Larkin K, Hita AG, et al. Stoma-related complications and emergencies. Int J Emerg Med. 2022; 15 (1).doi: 10.1186/s12245-022-00421-9 . | Open in Read by QxMD
  13. Morss‐Walton PC, Yi JZ, Gunning M, et al. Ostomy 101 for dermatologists: Managing peristomal skin diseases. Dermatol Ther. 2021; 34 (5).doi: 10.1111/dth.15069 . | Open in Read by QxMD
  14. Shabbir J, Britton DC. Stoma complications: a literature overview. Colorectal Dis. 2009; 12 (10): p.958-964.doi: 10.1111/j.1463-1318.2009.02006.x . | Open in Read by QxMD
  15. Butler DL. Early Postoperative Complications Following Ostomy Surgery. J Wound Ostomy Continence Nurs. 2009; 36 (5): p.513-519.doi: 10.1097/won.0b013e3181b35eaa . | Open in Read by QxMD
  16. Burch J. An update on stoma appliance flanges and base-plates. Br J Community Nurs. 2009; 14 (8): p.338-342.doi: 10.12968/bjcn.2009.14.8.43513 . | Open in Read by QxMD
  17. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. Circulation. 2013; 129 (25 suppl 2): p.S102-S138.doi: 10.1161/ . | Open in Read by QxMD
  18. Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures – 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis. 2020; 16 (2): p.175-247.doi: 10.1016/j.soard.2019.10.025 . | Open in Read by QxMD
  19. Aminian A, Chang J, Brethauer SA, Kim JJ. ASMBS updated position statement on bariatric surgery in class I obesity (BMI 30–35 kg/m2). Surg Obes Relat Dis. 2018; 14 (8): p.1071-1087.doi: 10.1016/j.soard.2018.05.025 . | Open in Read by QxMD
  20. Poirier P, Cornier M-A, Mazzone T, et al. Bariatric Surgery and Cardiovascular Risk Factors. Circulation. 2011; 123 (15): p.1683-1701.doi: 10.1161/cir.0b013e3182149099 . | Open in Read by QxMD
  21. Ma IT, Madura JA 2nd. Gastrointestinal Complications After Bariatric Surgery. Gastroenterol Hepatol. 2015; 11 (8): p.526-35.
  22. Mierzwa AS, Mocanu V, Marcil G, et al. Characterizing Timing of Postoperative Complications Following Elective Roux-en-Y gastric Bypass and Sleeve Gastrectomy. Obes Surg. 2021; 31 (10): p.4492-4501.doi: 10.1007/s11695-021-05638-w . | Open in Read by QxMD

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