Various portions of the small intestine are resected for a variety of reasons. Emergency procedures involving interference with the blood supply by a strangulated hernia, a volvulus due to a fixed adhesion, mesenteric thrombosis, traumatic injuries, localized tumors, and regional enteritis are among the indications for small bowel resection. Occasionally it may be judicious to perform an enteroenterostomy in the presence of many adhesions or extensive regional ileitis in an effort to avoid further resection of the already shortened small bowel resulting from previous extensive resections.
The indications for operation control the time allotted for fluid, electrolyte, and blood replacement (see Chapter 44). Constant gastric suction is instituted. An inlying catheter for drainage of the bladder is useful in monitoring the adequacy of urinary output in response to treatment. When the pulse is elevated and gangrenous intestine is suspected, plasma expanders or red cells may be administered. Intravenous antibiotics are given, and the patient is aggressively rehydrated using central venous pressure and urinary output as monitors.
The stomach should be on constant gastric suction, and the suction should be adequate to avoid the danger of aspiration of gastric contents. A cuffed endotracheal tube is advisable to seal off the trachea and avoid the possibility of aspiration pneumonia.
The patient is placed in a comfortable position with the operating table elevated at right angles to the working level of the surgeon. A modest reverse Trendelenburg position may be helpful in improving subsequent exposure as well as in the retraction of dilated small bowel.
The skin is prepared in the usual manner.
The incision is made in the general area of the suspected lesion. In the trauma patient, a long midline incision ensures adequate exposure for an extensive exploration. When an incarcerated hernia is likely to contain gangrenous intestine, some prefer to open the abdomen with an oblique incision above the groin in order to divide the viable bowel above the point of incarceration, lessening the chances of gross contamination when the hernial sac is opened. In the presence of previous scars, especially in the midline, a new incision may be judiciously made beyond the end or to one side in order to lessen the chance of injuring the underlying, probably tightly adherent small intestine.
A specimen of abdominal fluid is taken for culture and its color and odor evaluated as predictors of “dead intestine.” The release of restrictions by adhesions or a hernia sac is the first priority in the hope that a return of adequate blood supply will follow. When the viability of the intestine is questioned, the bowel may be placed in warm, moist gauze for ...