This resection is usually an emergency procedure used in the presence of sudden obstruction, such as gangrenous intestine in a strangulated hernia or from volvulus. Less frequently, it is used in mesenteric thrombosis and obstruction by tumor. Because an end-to-end anastomosis more accurately restores the natural continuity of the bowel, it is usually preferable to a lateral anastomosis, but the surgeon should be familiar with the side-to-side anastomosis, which is favored when there is marked disparity between the sizes of the ends of bowel to be anastomosed.
Because resection and anastomosis of the small intestine usually constitute an emergency procedure, preoperative measures are necessarily limited. However, before operation is attempted, the stomach is emptied and constant gastric suction maintained. Fluid and electrolyte balance, including normal sodium, chloride, and potassium levels, should be established in accordance with the degree of fluid and electrolyte depletion and the age and cardiac status of the patient. Antibiotic therapy should be instituted if gangrenous intestine is suspected. The pulse should be slowed and a good output of urine established as evidence of adequate blood volume expansion before surgery. Constant bladder drainage may be necessary to accurately determine the urinary output in elderly or seriously ill patients.
General anesthesia with an endotracheal tube and cuff, which permit complete sealing of the trachea, is recommended and, along with preoperative gastric decompression, is the best prophylaxis against possible aspiration pneumonia. Spinal anesthesia, either by single injection or continuous technique, may be used. However, the threat of sudden regurgitation of large volumes of upper gastrointestinal juices from the obstructed intestine must be anticipated by readily available competent suction equipment. The danger of aspiration is ever present even if an endotracheal tube is used.
The patient is placed in a comfortable supine position.
The skin is prepared routinely. Sterile drapes are applied according to the surgeon's specifications. Then a time-out is performed.
The incision is placed over the suspected site of the lesion. If the location of the small bowel obstruction is not known, a lower midline incision is often used because the lower ileum is most frequently involved. The incision is made preferably above or below an old abdominal scar, if present, because the site of the obstruction most likely will be near this point, especially if the scar was tender before operation. A culture of the peritoneal fluid is taken, and the amount, color, and consistency are noted. Bloody fluid indicates vascular obstruction. The dilated loops of intestine are retracted or removed carefully from the peritoneal cavity to a warm, moist surface and covered with gauze packs soaked in warm saline solution.
When strangulation is present, the ...