Chapter 52 - 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, Crohn's disease, 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 immunosuppressed patients.

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, take-down 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, with the majority of conversions being secondary to dense adhesive disease or excessive intra-abdominal inflammation.

Open segmental resection and end-to-end anastomosis with suture or staples usually can be performed in 20 minutes. Simple laparoscopic segmental small bowel resection can be accomplished in under an hour. Major laparoscopic resections, particularly those involving the colon in addition to the small bowel, generally take 2–5 hours. Resection of a wide section of accompanying mesentery is only required for malignant neoplasm and not in cases of benign disease. With the exception of resections 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.