CHAPTER 94 Brian J. Albers The small intestine is a continuation of the gastrointestinal (GI) tract, extending from the duodenal bulb to the ileocecal valve. It comprises the luminal mucosa, an inner circular layer and outer longitudinal layer of muscle, and the external serosa. For surgical purposes, the small bowel has two layers: the inner mucosa and the outer serosa. Blood is supplied by the mesentery, whose vessel of origin is the superior mesenteric artery and vein. Isolation of the segment to be resected is done with noncrushing clamps across the bowel proximally and distally (Fig. 94–1). The mesentery is taken down with clamps and ligated with 2–0 silk free ties (Figs. 94–2 and 94–3). If a handsewn anastomosis is desired, the bowel is sharply divided along the edge of a noncrushing clamp. The injured segment is removed, and the two ends of remaining small bowel are opposed and held aligned with traction sutures of 3-0 silk (Fig. 94–4). Circumferential, single-layer, 3-0 silk, interrupted sutures are used for the anastomosis (Fig. 94–5) with inversion of the mucosa (Fig. 94–6). All sutures are placed under direct visualization (Fig. 94–7), with palpable confirmation of a patent anastomotic ring (Fig. 94–8). The mesenteric defect is then closed to prevent internal herniation (Fig. 94–9). If a stapled anastomosis is planned, the resected segment is excised with successive firing of a GIA 75-mm stapling device. The proximal and distal segments are then affixed in parallel with seromuscular sutures at the inner mesenteric border (Figs. 94–10 and 94–11). Enterotomies are created to admit the stapler (Fig. 94–12), which is fired as the bowel segments are rotated to oppose the antimesenteric borders of each segment (Fig. 94–13). The anastomosis is briefly inspected for significant mucosal bleeding. If none is found, the enterotomy is then grasped with Allis clamps. The edges are opposed perpendicular to the direction of the side-to-side anastomosis just created (Fig. 94–14). Firing the GIA across and under the clamps creates a functional end-to-end anastomosis (Fig. 94–15). The mesenteric rent is then closed. Repair of a transmural injury may be performed on unprepped small bowel with minimal risk, as long as good technique is used. The edges of the perforated bowel should be trimmed before suturing. Simple transmural lacerations not involving the mesentery may be closed transversely (Heineke-Mikulicz operation closing the wound so as not to constrict the lumen) by placement of corner traction sutures and single-layer interrupted 3-0 silk (Figs. 94–16 and 94–17
Small Bowel Repair/Resection
David J. Lamon
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