SMALL BOWEL RESECTION

Indications

• Ischemia

• Tumor

• Trauma

• Stricture

• Obstruction

Essential Steps

1. Midline incision

2. Explore the abdomen

3. Mobilize the bowel to be resected (lyse adhesions if necessary)

4. Create a window in the mesentery at the resection edge in the avascular area

5. Divide the mesentery

6. Clamp/staple and divide the bowel

7. Remove the specimen (mark proximal/distal ends)

8. Stapled anastomosis:

– Create enterotomy at stapled ends for anastomosis

– Approximate enterotomies

– Fire liniear cutting stapler

– Inspect lumen for bleeding

– Close enterotomies (staple/suture)

– (Or suture anastomosis)

9. Check the anastomosis for patency and integrity

10. Close the mesenteric defect

11. Check hemostasis

12. Close the abdomen

Note These Variations

• Extent of resection, length of the remaining bowel (if extensive)

• Stapled vs sutured anastomosis

Complication

• Anastomotic leak

• Intra-abdominal abscess

• Enterocutaneus fistula

• Obstruction

• Malabsorption/short gut syndrome

• Hernia

Template Operative Dictation

Preoperative diagnosis: Intestinal ischemia/tumor/trauma/other.

Procedure: Exploratory laparotomy with small bowel resection

Postoperative diagnosis: Same

Indication: The patient is a _____ -year old man/woman with signs and symptoms of (list) and a preoperative diagnosis of (detail). Small bowel resection indicated for management of ischemia /tumor/trauma/other.

Description of Procedure: An epidural catheter was placed by anesthesia prior to the start of the operation. The patient was placed in the supine position and general endotracheal anesthesia was induced. Preoperatif antibiotics were given. A Foley catheter and nasogastric tube were placed. The abdomen was prepped and draped in the usual sterile fashion. A vertical midline incision was made from xiphoid to just below the umbilicus. This was deepened through the subcutaneous tissues and hemostasis was achieved with electrocautery. The linea alba was identified and incised and the peritoneal cavity entered. The abdomen was explored (list any abnormal findings). Adhesions were lysed sharply under direct vision with Metzenbaum scissors.

(Choose one:)

If ischemia: The segment of nonviable small bowel was ___ cm long and began ___ cm from the ligamentum of Treitz/ended ___ cm from the ileocecal valve. The margins were determined to be viable by arterial Doppler.

If tumor or trauma: The region of the tumor/perforation or stricture was identified and the extent of resection determined so as to achieve an adequate margin and allow resection of a fanshaped portion of mesentery with accompanying lymph nodes/allow anastomosis to be performed in a region of normal bowel.

A window was created by using a curved hemostat to separate the mesentery from the bowel at each resection margin. The mesentery was scored and serially divided with hemostats, and the vessels were then ligated with 3-0 silk ties.

If stapled anastomosis: The bowel was divided with a cutting linear stapler at each resection margin and passed off the table as a specimen (label proximal and distal margins for ischemia or tumor). The antimesenteric angles of the proximal and distal segments were then approximated with two sutures of 3-0 silk placed approximately 5 cm apart. Enterotomies were made at the antimesenteric borders and the cutting linear stapler inserted and fired. The lumen was inspected for hemostasis. The enterotomies were closed with a single firing of a linear stapler/in two layers with 3-0 vicryl and 3-0 silk.

If sutured anastomosis: A pair of noncrushing bowel clamps were placed on the bowel clamps were placed on the bowel at each resection margin. The small bowel was then transected between clamps with a #10 scalpel and passed off the table as a specimen (label proximal and distal ends for tumor or ischemia). The small bowel was then brought together approximating the ends. A two-layer anastomosis was created with a inner layer of running 3-0 silk Lembert sutures completely imbricating the inner layer.

The anastomosis was then inspected for patency and integrity. The mesenteric defect was closed with a running 3-0 vicryl suture. The abdomen was irrigated with 2 L of saline. The remaining small bowel appeared viable. The resection site was ___ cm from ileocecal valve/ligament of Treitz, and the patient had ___ cm of small bowel remaining.

(Optional: Multiple interrupted through-and-through retention sutures of ___ were placed.) The fascia was closed with u running suture of ___ /a Smead-Jones closure of interrupted ___. The skin was closed with skin staples/subcuticular sutures of ___/other.

The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.

Obstruction Ileus due to Adhesive

CASE IV

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OBTURATOR HERNIA

Obturator hernia: a new technique for repair

An obturator hernia is exceedingly rare and the diagnosis is usually made at laparotomy for small bowel obstruction. Several methods of dealing with the hernial defect have been described. Two cases of obturator hernias in nonagenarians are reported and a new, simple and effective method of repairing the hernia by suturing a polypropylene (Prolene) mesh to Cooper’s ligament is proposed.

OPERATIVE TECHNIQUE

The hernia was reduced by gentle traction on the bowel. The sac was inverted and excised after ligating the neck with 2-0 Vicryl (Ethicon Ltd, P0 Box 408, Bankhead Avenue, Edinburgh EH11 4HE, UK). The peritoneum over the pecten pubis was incised and elevated to expose the obturator canal, internal obturator fascia and iliac vessels. A 6 x 11 cm polypropylene (Prolene Ethicon Ltd) mesh was sutured to Cooper’s (pectineal) ligament with 2-0 Prolene. Medially, the mesh was sutured to the fascia over the pubis to cover the pubic symphysis (Figure 1). The mesh was left to hang and cover the obturator canal and reperitonealized by suturing the incised peritoneum with 2-0 Vicryl. The repair was completed in 10 minutes.

DISCUSSION

Obturator hernias are rare and a pre-operative diagnosis is exceptional, the vast majority being diagnosed at laparotomy for small bowel obstruction.^1-3 A midline laparotomy is therefore the favoured approach. Excellent views of the obturator canal, nerve and vessels are obtained and a bowel resection, necessitated in up to 80% of cases,² is easily performed.

There are several ways of repairing the hernial defect, though some prefer leaving it open. The recurrence rate of unclosed defects is not known. Closure of the defect with single or multiple sutures risks damaging the obturator nerve and vessels and some defects are too large to close by simple suture.³

Figure 1 Diagrammatic representation of operative repair showing polypropylene mesh sutured to Cooper’s ligament and covering the obturator canal.

Various methods of mesh repair have been attempted (Table 1), but the present technique is unique in its simplicity and that all sutures are placed away from vital structures, thus minimizing the possibility of injury. Procedures utilizing the uterine fundus, round ligament or bladder distort normal anatomy and the insertion of foreign bodies into the obturator canal could compress the neurovascular structures similar to the hernia. The repair described herein does not appreciably prolong the operation and the incidental reexploration of one patient established its efficacy. Bilateral hernias are easily tackled and this method could be used for laparoscopic obturator hernia repair.

Table 1 Techniques for repair of obturator hernia

Reference	Technique
Short BMJ 1923; 1:718	Inserted plug of costal cartilage into obturator ring
Horine Ann Surg 1927; 86: 776—81	Inverted apex of sac and sutured sac to perironeum
Grey-Turner quoted in Lancet 1938; 1: 721—2	Inverted sac from within and ligated the base
Wakeley BrJSurg 1939; 26: 515—25	Ligated sac; sutured innermost fibres of pectineus muscle to periosteum of obturator canal
Throckmorton Surgery 1950; 27: 888—92	Sutured tantalum gauze, to periosteum of pubic ramus and to obturator membrane
Pender BMJ 1950; 2:1038	Thigh incision. Plugged obturator canal with rolled up tantalum gauze held in place by suturing adductor brevis over lower end
Rothman NYJMed 1951; 51: 1186	Used a patch of peritoneum to close defect
Stone and McLanahan In: Lewis DD, ed. Practice of Surgery. Vol. 7 Hagerstown: Prior, 1954: 68—9	Elevated an osteoperiosteal flap from pubic bone and rotated it to close defect
Harper and Holt AmJSurg 1956; 92: 562—5	Used a simple purse stringsuture at neck of sac
Gilfillan Can JSurg 1958; 1: 366—7	Everted and ligated sac. Filled defect with plug of free omentum
Rogers Surgery 1960; 48: 394~403	Sutured patch of Teflon around defect
Hanley and Hanna IrMed 11970; 63: 396—8	Used uterine fundus to obliterate defect
Larrieu and DeMarco Am Surg 1976; 42: 273—7	Sutured Marlex mesh around defect. Uterus and round ligament used to reinforce mesh
Aurousseau et at. J Chir 1978; 115: 35—8	Used round ligament to obliterate defect
Arbman Acta C/sir Scand 1984; 150: 3 37—9	Sutured wall of urinary bladder to pelvic wall and round ligament to obliterate defect
Bjork Surg Gynecol Obstet 1988; 167: 217—22	Used locally available obturator fascia to repair defect
Carriquiry and Pineyro Bri Surg 1988; 75: 785	Placed a polypropylene mesh beneath pubis, covering both obturator foramina
Tchupetlowsky etal. Surgery 1995; 117: 109—12	Inserted cylinder of Ampoxen mesh into obturator canal. Mesh secured with Policon sutures
Bergstein and Condon Surgery 1996; 119:133—6	Both obturator foramina covered with preperitoneal Marlex mesh. Mesh sutured to endoabdominal and endopelvic fascia

The peritoneal dissection must extend to expose the iliac vessels to enable insertion of the entire mesh and prevent rolling of its free lower border. It is important not to trim the mesh because a greater surface area minimizes the possibility of displacement before the interstices are infiltrated by fibroblasts. Medial fixation of the mesh to the pubic tuberele and fascia over the symphysis is recommended. These precautions are also said to reduce the recurrence rate of laparoscopic inguinal hernia repairs.⁴

Polypropylene is an ideal mesh material because it is inert, strong, thin and non-absorbable. It lacks intrinsic antibacterial activity, but is capable of withstanding infection.⁵ Outpatients have shown that with antibiotic prophylaxis it is safe to use polypropylene mesh and perform a small bowel resection, but we would not recommend it in the presence of peritonitis.

In conclusion, this method of obturator hernioplasty is simple, safe, effective and easily reproducible. The rapidity with which the repair is performed makes it particularly suitable in elderly patients in whom it is vital to minimize operating time.

REFERENCES

1. Bjork KJ, Mucha P, Cahill DR. Obturator hernia. Surg Gynecol Obstet
2. 1988; 167: 217—22.
3. Lo CY, Lorentz TG, Law PWK. Obturator hernia presenting as small bowel obstruction. AmJSurg 1994; 167: 396—8.
4. Rogers FA. Strangulated obturator hernia. Surgery 1960; 48: 394—403.
5. Brough W, Royston C. TAPP repair: the Hull and Stockport experience. In: Darzi A, Monson JRT, eds. Loparoscopic Inguinal Hernia Repair. Oxford: Isis Medical Media, 1994: 48—61.
6. Walker AP. Biomaterials in hernia repair. In: Nyhus LM, Condon RE, eds. Hernia. Philadelphia: Lippincott, 1995: 534—40.

Incarcerated Obturator Hernia

CASE III

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Jejunal Rupture

Jejunal Rupture

The diagnosis of blunt small bowel rupture is suspected when abdominal tenderness, pneumoperitoneum or a positive DPL is present. Extravasation of contrast material during computed tomography (CT) scanning is rare. When free fluid is detected in the abdomen by CT scan without a solid organ injury, a hollow viscus injury should be suspected.
Injury to the small bowel is evaluated intraoperatively by “running the bowel”: the small bowel and its mesentery are inspected in a systematic and comprehension fashion from the ligament of Treitz cauded to the ileocecal valve. As active mesenteric bleeding is ancountered, it is controlled by isolation and individual ligation of the bleeding vessels rather than by mass ligation of the mesentery, which may produce ischemia. Likewise, as bowel perforation are found, temporary control measures are rapidly initiated in an effort to prevent excessive or ongoing soilage. Once all bowel injuries are accounted for, the decision must be made whether to perform primary repair, resection of the injured segment, or some combination of the two. Primary repair of multiple injuries preserve bowel length and is generally preferred. At the discretion of the operating surgeon, resection of a segment containing multiple injuries may be performed to expedite the operation, provided that the amount of bowel to be resected is small enough that its loss would have only a negligible effect on digestive function.

Management of each individual wound is determined by its severity according to the AAST grading system. Small partial-thickness injuries (grade I) are managed by reapproximating the seromuscular layers with interrupted sutures. Small full-thickness wounds (grade II) are repaired with limited debridement and closure. Closure is performed in either one or two layers (we prever a two layers closure), and transverse closure is preferred to avoid luminal narrowing. Large full-thickness wounds (grade III) may be repaired primarily if luminal narrowing can be avoided; otherwise, resection and anastomosis should be performed. Extensive wounds and wounds associated with devascularization (grade IV and V) are treated with resection and anastomosis. When mesenteric injury is encountered in the absence of bowel injury, the associated bowel must be closely assessed for evidence of vascular compromise. If the bowel appears viable, the rent in the mesentery should be reapproximated after bleeding is controlled to prevent an internal hernia. If there is evidence of vascular compromise, bowel resection and anastomosis are indicated.

Jejunum Rupture

Jejunum Rupture

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Upper-Extremity Thromboembolectomy

Indication:
Acute upper-extremity ischemia secondary to embolism or thrombotic event
Essential Steps:
1. Identify the likely site of obstruction, based on history and physical exam.
2. Obtain proximal and distal control.
3. Circumferential dissection of the brachial artery at the antecubital fossa.
4. Circumferential dissection of the origin of the radial and ulnar arteries.
5. Make arteriotomy (transverse vs longitudinal).
6. Catheter thromboembolectomy (avoid overdistension and repeated passes).
7. Artery closure (primary vs patch).
8. Asses distal perfusion.
9. Evaluated the arm for compartment syndrome.
Note these variation:
- The brachial artery can be exposed through a transverse or S-shaped skin incision overlying the antecubital fossa.
- Dissection of the origin of the radial and ulnar arteries is optional.

Complications:
- Bleeding
- Infection
- Ongoing ischemia
- Compartment syndrome
- Limb loss

Description of procedure:
The procedure was performed under local/axillary block/general anesthesia. With the patient in the supine position, the right/left upper extremity was prepped and draped in the usual steril fashion. The skin over the antecubital space was infiltrated with 1.0/0.5% lidocaine. A 5-cm skin incision overlying the antecubital fossa was then performed and deepened through the subcutaneous tissue and fat. The biceps aponeurosis was incised over he brachial pulse. The brachial artery was circumferentially dissected to its bifurcation into the ulnar and radial arteries. The patients was already receiving heparin anticoagulation. The brachial artery was controlled with silastic vessel loops and a transverse arteriotomy was performed. Clot was extruded and good inflow was established. The same was then performed to the radial artery. Thorough irrigation with heparinized saline was then performed. The arteriotomy was closed using 6-0/7-0 interrupted/running sutures. At the completion of the procedure, there was evidence of palpable pulse in the radial/ulnar arteries. The suture line was hemostatic. The wound was then irrigated with antibiotic solution and closed using 3-0 vicryl for the subcutaneous tissue and 4-0 monocryl for the skin.
The patient tolerated the procedure well and was transferred to the postanesthesia care unit in stable condition.

Thromboemboli at brachial artery

Vascular Trauma

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