SMALL INTESTINE

In nonviable small intestine:

Make the decision to resect a part of the small intestine after you have inspected the entire gut. If there is a perforation in the intestine, repair the wound with a purse string invaginating suture or with a transverse two layer invaginating closure.

When several wounds are close together, or if the gut is ischaemic, resect the damaged loop and make an end-to-end anastomosis.

Reasons for resection include:

Techniques

Closure of a small wound

::	Expose the wounded portion of the intestine (Figure 6.29) and pull the gut transversely with stay sutures (Figure 6.30).
Figure 6.29
Figure 6.30
::	Insert the first layer of invaginating sutures to include all layers of the gut wall (Figure 6.31). The second layer, serosa to serosa, completes the repair (Figure 6.32).
Figure 6.31
Figure 6.32

Resection

1	Determine the extent of the loop to be resected, including a small margin of healthy gut on either side (Figure 6.33). Hold up the loop so that you can see the mesenteric vessels against the light. Plan to divide the mesentery in a V-fashion or separate it from the intestinal wall, depending upon the length of the mesentery.
Figure 6.33
2	Isolate the mesenteric vessels by making blunt holes in the mesentery on either side of the vessel. Doubly ligate each vessel and then divide it between the ligatures (Figures 6.34, 6.35). Continue dividing the mesentery until you have isolated the section of gut to be resected.
Figure 6.34
Figure 6.35
3	Apply crushing clamps to both ends of the isolated loop and gently “milk” the normal bowel above and below the loop to move contents away from the planned point of resection. Once these sections of gut have been emptied, apply light occlusion clamps to the bowel 3–4 cm beyond the crushing clamps.
4	Under the loop of bowel, place a swab that has been soaked in saline and wrung out. Holding the knife blade against one of the crushing clamps, divide the gut (Figure 6.36).
Figure 6.36
5	Clean the exposed part of the lumen and discard the used swab. Temporarily release the occlusion clamp and check to see whether the cut ends of the bowel bleed freely. If so, reapply the clamp. If not, resect the bowel further until it bleeds freely. The healing of the anastomosis depends on a good supply of blood. Confirm that the section of gut between the second pair of clamps also has a good blood supply.

Anastomosis

1	Make the anastomosis carefully using a two-layer technique. Use continuous sutures of 2/0 absorbable suture on a half circle atraumatic needle. First, bring together the occlusion clamps and hold them in position to oppose the cut ends of the bowel (Figure 6.37). Check the proper orientation of the gut and steady the tissues by joining the cut ends with seromuscular stay sutures at each end of the planned anastomosis (Figure 6.38).
Figure 6.37
Figure 6.38
2	Begin the anastomosis by inserting the inner layer of absorbable sutures. Start at one corner of the bowel, knotting the suture to anchor it (Figure 6.39). Leave one end long enough to be held with forceps. Use the other end with the needle to make a continuous “over-and-over” stitch through the full thickness of the gut wall (Figure 6.40). When the back is completed, pass the needle out from the mucosa to the serosa on one side and then back from the serosa to the mucosa on the other (Figure 6.41). Invert the corner by applying traction to the axis of the suture line and suture the anterior wall as an “under-and-under” stitch to invaginate the edge of the bowel (Figures 6.42, 6.43). Continue the stitch back to the origin and knot it to the end that has been left long (Figures 6.44, 6.45). Remove the occlusion clamps.
Figure 6.39
Figure 6.40
Figure 6.41
Figure 6.42
Figure 6.43
Figure 6.44
Figure 6.45
3	Place a second continuous suture by picking up the serosa and muscle coats on both sides of the bowel, covering the previous suture line (Figure 6.46). Tie this suture to the stay suture at the end and turn the bowel over. Continue the suture to cover the other side of the anastomosis. Cut the ends of the stay sutures. The second layer can also be closed with interrupted absorbable or non-absorbable suture.
Figure 6.46
4	Close the mesentery with interrupted 2/0 absorbable suture, taking care not to puncture the blood vessels. Check the adequacy of the stoma by palpation: it should admit the tip of the thumb and finger (Figure 6.47). Close the laparotomy incision.
Figure 6.47