In this BoardsCast episode, we continue Tobias Chapter 92 - Small Intestine by confronting the most dangerous belief in intestinal surgery:

“It’s pink. It moves. It’s fine.”

That assumption kills patients.

Because small intestine can look alive while it is already biologically doomed—and the failure doesn’t declare itself in the OR. It declares itself 48–72 hours later as septic peritonitis. 

This episode rebuilds your viability assessment around perfusion and physiology, not cosmetics. You’ll learn why surgeons accidentally create dead bowel, why venous congestion can kill faster than arterial loss, and the non-negotiable rules for safe margins and anastomoses. 

You’ll learn:

• Why color, peristalsis, and pulsation are unreliable predictors of intestinal survival 
• How the anatomy sets a trap: arcades → vasa recta end-arteries = no collateral “plan B” 
• Why venous congestion creates the ischemic lie (blood present ≠ blood cycling) 
• How edema kills bowel by increasing diffusion distance—so tissue “dies later” after you close 
• The 5 ways surgeons create ischemia: bad ligation, stripping mesentery, tension, handling/edema, and the “cowardice of preservation” 
• Why perfusion margins matter more than visual margins (and what “aggressive bleeding” actually means) 
• The ischemic failure cascade: day 0 looks good → microleaks → translocation → day 3–5 septic collapse 
• Defensive engineering: resect more, appositional closure, gentle knots, and why omentum is mandatory (plus when a serosal patch saves the case) 

This episode teaches you to stop trusting what bowel looks like and start trusting what bowel can survive.

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