Small Bowel Resection

Definition

• Excision of a segment of the small intestine with an anastomosis to a segment of more distal small bowel or colon, thus restoring continuity of the gastro intestinal tract.

Discussion

• This procedure is performed to remove an obstruction, a gangrenous portion of bowel, a perforation, or a source of hemorrhage within the small bowel.
• Small bowel resections are infrequently performed as an isolated procedure, except for inflammatory bowel disease. They are done in conjunction with other procedures because of adhesive obstructive disease, tumors of adjacent organs, diverticulitis, or tuboovarian abscess.
• Two techniques frequently used to perform the anastomosis:
  1. End-to-end: two ends of several bowel are brought in close approximation, rotated slightly outward, and joined.
  2. Side-to-side: two surface layers are joined on each side of a suture line, creating an opening on each side, exposing the intestinal mucosa, which is then approximated.

Position

• Supine, with arms extended on armboards.

Incision Site

• Upper midline (isolated procedure)

Packs/ Drapes

• Major Lap pack
• Four folded towels

Instrumentation

• Major Lap tray
• Intestinal instruments
• Internal stapling instruments
• Hemoclips/ surgiclip applier

Supplies/ Equipment

• Basin set
• Blades – (2) #10, (1) #15
• Hemoclip/ surgiclip
• Suction
• Needle counter
• Internal surgical staples
• Suture (surgeons preference)
• Solutions – saline, water
• Dressings
• Medications – surgeons preference

Procedure Overview

As an Isolated Procedure

1. To identify the decreased portion of the intestines, the surgeon will use an upper midline approach, and then explore the intestines by passing the loops of the intestine through his/her fingers. This technique is called “running the towel”.
2. Once the area has been identified, the section between the proposed site of anastomosis must be isolated from the attached mesentery.
3. Using a metzenbaum scissors, the surgeon makes a small incision into the avascular area of the mesentery.
4. Two Kelly clamps are placed over a section of mesentery, and the section is divided with a knife or cautery pencil between the two clamps; then it is ligated. This process is continued, until the diseased portion and the anastomosis site have been isolated.
5. Two intestinal clamps are placed at each end of the isolated segment, and the tissue is divided with a knife or cautery pencil.
6. The affected segment is excised, and continuity of the bowel is restored by either the use of sutures, or the application of internal staples used to both create the anastomosis and restore flow through the bowel.
7. The abdomen is irrigated with warm saline, and closed in layers in a routine fashion.

As part of another procedure

1. Similar steps are taken, leaving restored segment attached to the adherent ogran also resected.

Perioperative Nursing Consideration

1. The surgeon may request a clean closure set up, or may only require the isolation of the instruments, depending on the segment of bowel beong repaired.
2. As a general rule, when working with the jejunum or below, bowel technique should be employed, as opposed to a no-touch technique.
3. When part of another procedure, the small bowel segment will be performed following the revision of the diseases area, and appropriate instrumentation for that procedure should be available.
4. If an ileostomy appliance (karaya seal, etc) may be placed on the patient prior leaving the operating room.