Key principles
• Excise diseased small bowel and perform a tension free well vascularised anastomosis • For benign disease excise to macroscopically normal margins • For malignant disease typically aim for 5cm margins and wedge of mesentery incorporating draining lymphatics
Operation Details
• Position supine. NG if obstructed • IV Cefuroxime and Metronidazole • Typically performed via midline laparotomy • Run entire small bowel to document location of resected bowel and length of resected and remaining bowel • Decide on resection margins and divide mesentery with Dunhills forceps and 2/0 vicryl ties • Check proposed margins healthy • Soft bowel clamps proximally and distally and then crushing bowel clamps • Divide bowel with scalpel • Ensure tension free and well vascularised ends • Perform anastomosis with interrupted seromuscular 3/0 PDS. Start by placing stay sutures at antimesenteric border and mesenteric border and place row is sutures between. Flip to complete posterior wall. • Remove soft bowel clamps and check for leak • Close mesenteric defect 3/0 vicryl • Complete laparotomy and close rectus sheath with loop 1 PDS and close skin
Intraoperative complications & challenges
• Unwell patient or large area of potentially non-viable bowel – consider resected clearly necrotic bowel, stapling off ends and returning for relook in 24 hours. At that stage consider anastomosis or stoma depending on location
Post-operative complications
• Immediate o Bleeding o Need for extended resection • Early o Anastomotic leak o Infection/collection/abscess • Late o Short gut o Nutritional deficiencies – B12, Bile salts etc o Stricture o Adhesions
Specific post-operative care
• Dependent on aetiology • If obstruction typically keep NG until outputs decrease then slow transition to diet