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.