47 - Small bowel resection

Summary

Small bowel resection is performed in a variety of settings, the most common of which are traumatic perforation, thrombotic or embolic infarction, regional enteritis, and concomitant colectomy. Less common indications for resection include benign or malignant neoplasms (leiomyoma, hemangioma, carcinoid, lymphoma, adenocarcinoma, sarcoma), fistula resulting from a previous repair or resection, symptomatic Meckel's diverticulum, neutropenic enterocolitis, and spontaneous perforation in patients with cancer who are receiving chemotherapy and corticosteroids.

The most significant change in the operative management of small bowel disease in recent years has been the increasing use of laparoscopic approaches. In patients with inflammatory small bowel disease, laparoscopic operations now include diversion for complex fistula, takedown of end or loop stoma, segmental resection, stricturoplasty, and lysis of adhesions. Conversion rates to an open approach have ranged from 2%–40% in series published since 1993. Such conversions are most often due to dense adhesions from prior operations and excessive inflammation.

Open segmental resection and end-to-end anastomosis with suture or staples usually can be performed in 20 minutes. Major laparoscopic resections, particularly those involving the colon in addition to the small bowel, generally take 3 to 5 hours. With the exception of those performed for a neoplasm in the adjacent right colon, most resections of the small bowel for trauma, infarction, or inflammatory bowel disease cause moderate to severe stress. General anesthesia is used, the duration of the procedure depends on the indication, and blood transfusions are necessary only in patients with trauma, extensive inflammation, or infiltrating neoplasms.