Small bowel resection and anastomosis

Indications

• Congenital lesions i.e.: atresia, duplication
• Traumatic perforation
• Critical ischaemia
• Crohn’s disease or other cause of stricture
• Tumours of the bowel or its mesentery

Preparation

• Adequate hydration and nasogastric intubation
• Appropriate prophylactic antibiotics

Technique

• Isolate the diseased loop of bowel from the other abdominal contents by means of a large towel
• Hold up the bowel and examine the mesentery against the light
• Determine the proximal and distal sites for dividing the bowel, and select the line of vascular section in between; keep fairly close to the bowel wall (except when resecting a neoplasm)
• Incise the peritoneum along this line to expose the mesenteric vessels
• Ligate and divide the mesenteric vessels
• Apply four intestinal clamps
• First, 2 crushing clamps on either sides of the lesion
• Then, non-crushing clamps about 5cm outside each crushing clamp
• Place a clean towel beneath the clamps at each end
• Divide the bowel with a knife flush against the outer aspect of each crushing clamp
• Remove the segment of bowel and cleanse each end using povidone iodine

Anastomosis

• Assess the bowel ends for viability (colour, bleeding, peristalsis, mesenteric pulsations)
• Make sure that the suture lines are not under tension

Technique

• Single layer sero-submucosal sutures, using 2/0 or 3/0 absorbable sutures (polyglactin)

 

• 2 layer – technique – continous, using 2/0 or 3/0 absorbable sutures (outer layer should be preferably silk or poly glactin). 
• First layer – should catch the serosa and the muscle only.
• Second layer – full  thickness of the bowel.

 

 

 

 

 

2 layer technique

 

Serosa is the sealant layer.  When completed, the serosal approximation should be ensured.