Dogma, data, and decision-making: a history of treatment for small-bowel obstruction

BACKGROUND: Mechanical small-bowel obstruction (SBO) has been recognized since antiquity. We systematically review the evolution of its diagnosis and treatment, with emphasis on surgical milestones, influential surgeons, and procedural advances alongside the development of imaging and non-operative therapy. METHODS: We searched primary historical texts, monographs, and PubMed-indexed articles (inception to July 2025) for descriptions of mechanical SBO management. Data on key innovations, figures, outcomes, and global knowledge sharing were extracted and chronologically synthesized. Narrative synthesis followed SANRA criteria for scholarly reviews with emphasis on clarity of scope, critical interpretation, and structured presentation of key developments. RESULTS: Early sources solely describe non-surgical measures. In one of the first invasive interventions, Praxagoras of Cos (circa 350 BCE) reportedly advocated for surgical intervention in cases of intestinal obstruction, describing a decompressive enterocutaneous fistula as a therapeutic measure when purgation failed. Operative release of strangulated hernia was re-introduced by Ambroise Paré in the sixteenth century. Ether anesthesia (1846) and antisepsis (1867) enabled safe laparotomy; shortly thereafter, Sir Frederick Treves formalized the core operative principles in 1884. Plain abdominal radiography (1900s) improved diagnosis while Owen Wangensteen's nasogastric suction (1931) reduced mortality from > 60% to ~ 5%. Antibiotics, intravenous fluids, and stapled anastomoses further enhanced outcomes. Computed tomography (1980s) became the diagnostic gold standard, guiding selective non-operative management with enteral decompression and hyperosmolar contrast administration. Minimally invasive adhesiolysis, first embarked upon in the 1990s, now benefits carefully selected patients. CONCLUSIONS: Mechanical SBO care has evolved from basic supportive measures to structured, evidence-based therapy. Each advance addressed a specific clinical barrier: anesthesia enabled laparotomy, radiography enabled diagnosis, and decompression enabled non-operative management. As a result, SBO now exemplifies how iterative innovation can transform a once highly morbid emergency into a condition amenable to algorithmic, protocol-driven care. This historical arc offers instructive parallels for current surgical challenges.