Resection small intestine, especially when removing large areas of it, is a difficult intervention, the severity of which is determined not so much by its traumatic nature as by subsequent disorders of the digestive function.
Although there are known cases of favorable long-term results after resection of the small intestine from 5 to 6 m, however, often after much less extensive resections, dyspeptic symptoms subsequently develop, which lead to severe exhaustion of the patient. Cases of death from exhaustion have been described during resection of 1.5-2 m. There is no doubt that what matters here is not so much the size of the resected area, but the size of the remaining part of the intestines and its ability to digest. And since the length of the intestine is individually very different, and individuals the intestines can reach very large sizes, then favorable outcomes are clear even with resection up to 6 m. In general, resection of sections of intestine exceeding 1.5 m always carries the risk of subsequent digestive disorders.
After extensive resections of the small intestine, patients suffer from frequent diarrhea for the first days, which gradually stops, and in some of them normal digestion is subsequently restored; in a number of patients, diarrhea resumes with every violation of the diet and many of them become disabled. They constantly need strict diet, containing a lot of protein, a lot of easily digestible carbohydrates, and, if possible, little fat. The life of such patients is short-lived.
Video: Roma Meshko from Dneprodzerzhinsk, 4.5 years old, after resection of the small intestine
Small bowel resection technique
Resection should be performed with end-to-end anastomosis.
Video: History of my illness (Short bowel syndrome)
After determining the boundaries of the area to be removed, ligation of the vessels feeding it begins. The vessels need to be ligated in the area of the last extraintestinal branches of the mesenteric artery, going to the intestinal wall between the intestine itself and the nearest vascular arcade. Bandaging at the root of the mesentery is necessary when malignant tumors when, together with the tumor, it should be possible to perform complete removal lymphatic apparatus of the intestine.
To ligate the vessels directly near the intestine, 2 holes are made in an avascular place and the branches enclosed between the holes, together with the mesenteric layers covering them, are clamped with two strong hemostatic clamps, and then the vessels are crossed between them. In this way, the intestine is separated from the mesentery along the required length, after which the crossed vessels are ligated. The surgical field is delimited with gauze pads. The section of intestine separated from the mesentery is removed after crossing it at each end between 2 pulps.
The adducting end and efferent end of the intestine, clamped by the sphincter, are brought together, their walls, which are facing backward when the sphincter is in a horizontal position, are sewn together with interrupted serous-muscular sutures. In this way, the 1st floor of the sutures of the posterior wall is created, located 0.5-1 mm from the sphincter, clamping the ends of the intestine directly at the places of its cutting. The ends of all seams are cut off except the 2 extreme ones, which then serve as holders.
After this, the ends of the intestine with the sphincter applied to them are cut off, retreating 2 mm from the suture line towards the sphincter. The contents from the ends of the intestine are removed with a pump immediately when each of them is cut off.
Now the ends of the intestine are sewn together along the entire circumference with a continuous catgut suture. Rear wall sewn over the edge, and the front one - like a furrier's seam. Finally, the 2nd floor of seromuscular sutures is placed on the anterior lip of the anastomosis. After the anastomosis, the edges of the severed mesentery are sutured together.
If resection has to be carried out near the junction of the small intestine into the cecum, then there is always a danger of disrupting the blood supply to the remaining terminal section of the ileum, when its length does not exceed 3 cm. In such cases, it is safer to suture the remaining short efferent end tightly and immerse its stump in the cecum serous muscular sutures, and the adducting end is anastomosed with the cecum or ascending colon side to side.
Resection of the small intestine refers to the removal of one or another section of the intestine. Most often it is performed for tumors, strangulated hernias, intestinal obstruction, thrombosis of mesenteric vessels, wounds, etc. Resection of the small intestine should be carried out within healthy tissues: proximally 30-40 cm and distally 15-20 cm from the section of intestine to be resected.
Stages of small intestine resection:
Inferior midline laparotomy.
Audit abdominal cavity.
Mobilization of the mesentery of the small intestine (along the intended line of intersection of the intestine).
Bowel resection.
Formation of interintestinal anastomosis.
In the avascular zone of the mesentery of the small intestine, a hole is made with a clamp, on both edges of which one enteromesenteric serous suture is placed. In this case, the mesentery, the marginal vessel passing through it and the muscular layer of the intestinal wall are pierced without penetrating into the intestinal lumen. By tying a suture, the vessel is fixed to the intestinal wall. These sutures are placed along the resection line from both the proximal and distal sections. At a distance of about 5 cm from the ends of the intestine intended for resection, two intestinal clamps for coprostasis are applied, the ends of which should not extend beyond the mesenteric edges of the intestine. This position of the clamps preserves the blood supply to the mesentery in its peri-intestinal zone. Approximately 2 cm below the proximal clamp and 2 cm above the distal clamp, one crush clamp is applied.
The mesentery of the small intestine is crossed between the ligatures. Most often, a cone-shaped intersection of the small intestine is performed. In this case, the slope of the intersection line should always start from the mesenteric edge and end on the opposite edge of the intestine, due to the fact that only with this orientation is vascularization of the end to be anastomosed and the possibility of correct approximation of the edges of the crossed mesentery ensured.
7. Features of colon resection, taking into account its level and blood supply.
In most cases, colon resection is performed with radical removal cancerous tumor. The extent of resection is determined the following points:
At least 10 cm of intact part of the intestine must be resected on both sides of the tumor;
The resection line should pass through a well-moving segment of the colon, surrounded on all sides by the peritoneum;
If possible, the chain of lymph nodes and the vessels adjacent to them are radically removed.
Presence of critical areas of blood supply.
It is known that the right half of the colon receives blood from the superior mesenteric artery, the main trunk of which cannot be crossed due to the possibility of disruption of the blood supply to the entire small intestine. The situation is different with the left half of the colon, which is supplied with blood from the inferior mesenteric artery. Here the main trunk can also be ligated directly at the place of its origin from the abdominal aorta. Resection of the right half of the colon: When resection of the right half of the colon, the entire right half of the colon is removed, including 10-15 cm of the final segment of the ileum, the cecum, the ascending colon, the right flexure and the right third of the transverse colon. An ileotransverse anastomosis is performed between the ileal loop and the transverse colon. Due to the discrepancy between the width of the lumen of the small and large intestines, anastomoses are often performed side to side or the end of the small intestine to the side of the large intestine. When performing a side-to-side anastomosis, it must be remembered that leaving long blind ends can lead to a pathology known as blind pouch syndrome. Mobilization of the right half of the colon begins from the ileocecal angle, covering 10-15 cm of the ileum. To do this, the cecum and ascending colon are retracted inwards and, moving 1.5-2 cm outward from the cecum, the posterior parietal peritoneum is dissected with scissors along the right lateral canal, continuing the incision from the ileocecal angle along the outer edge of the cecum outgoing colon to the right bend. The cecum and ascending colon along with the mesentery are bluntly isolated inwardly. Next, the right flexure of the colon and the right third of it are mobilized. To do this, the hepatocolic ligament is crossed in parts between the clamps and tied with silk. The connective tissue cords between the duodenum and back surface right
bending of the colon with mandatory ligation of blood vessels. When isolating the right flexure, there is a danger of damaging the head of the pancreas and the pancreaticoduodenal artery, which can disrupt the blood supply duodenum. Then, between the clamps, the gastrocolic ligament is cut in parts and tied with silk over a distance of 7-8 cm from the right bend to the level of resection of the right third of the transverse colon. The greater omentum is removed according to the level of resection of the transverse
colon with vascular ligation. Then the mesentery is crossed in the area of the terminal ileum. To do this, moving 10-15 cm from the cecum with a Kocher clamp closer to the intestine, a hole is made in the mesentery of the ileum, a gauze holder is passed through it, with which the intestine is lifted, and from this place towards the cecum the mesentery of the ileum is crossed in parts between the clamps and tied with silk. Clamps are applied to the removed part of the colon and the terminal part of the small intestine, between which the intestines are dissected. The ileocolic artery, right colic artery, and branches of the middle colic artery should be ligated and dissected. When an ileotransverse anastomosis is applied side to side, the loop of the ileum anastomoses with the transverse colon isoperistaltically, i.e. their ends “look” in opposite directions. The side-to-side anastomosis should be located on the free side of the colon at a distance of 3-4 cm from its end and about 2 cm from the end of the ileum. In this segment, departing about 1 cm from the free band of the colon and 1 cm from the mesenteric edge of the small intestine, a back row of interrupted serous-muscular silk sutures is placed between them for 6-7 cm along the free band. Next, parallel to the back row of serous-muscular sutures at a distance of up to 1 cm from it, the lumen of the ileum is first opened, not reaching the outer threads-holders by 1 - 1.5 cm. Then, parallel to the incision of the ileum, the lumen of the colon is opened in the middle of the free tape. The inner row of sutures is applied through all membranes with a continuous entwining catgut suture or interrupted silk sutures, the outer row (serous-muscular sutures) is applied with interrupted silk sutures. The loop of the ileum on both sides of the anastomosis is additionally fixed to the colon with two or three interrupted sutures on each side.
Resection of the transverse colon.
The operation is indicated for the removal of a tumor located on the moving part of the transverse colon. It is advisable to begin the operation with the removal of the greater omentum in order to facilitate further manipulations. To do this, the greater omentum is lifted and cut off with scissors along the avascular zone near the intestine along the entire length from the right to the left bend of the colon. Next, the gastrocolic ligament is crossed in parts between the clamps. The mesentery of the transverse colon is divided between the clamps as far as possible from the intestinal wall. The middle colic artery is ligated and divided separately near its origin from the superior mesenteric artery. In case of cancer, it is advisable to ligate the artery and vein at the beginning of the operation. In case of benign processes in the transverse colon, it is advisable to preserve the middle colon artery, and to cross and ligate only its branches going to the part of the intestine to be removed. Hard intestinal clamps are applied to the removed part of the transverse colon on both sides, and then soft clamps; between them the intestine is crossed and removed. The patency of the colon is restored by applying an end-to-end anastomosis with double-row interrupted silk sutures according to the usual technique.
Resection of the left half of the colon indicated for a cancerous tumor of the left half of the colon, metastases of which are determined around the inferior mesenteric artery, left-side complicated ulcerative colitis, polyposis with malignancy, complicated diverticulitis, etc.
In this operation, the left third of the transverse colon, the left flexure, the descending colon and the sigmoid colon are removed to the middle or lower third with a transverse sigmoid anastomosis. More often, the entire sigmoid colon is removed down to the rectum with transversorectal anastomosis or ileocoloplasty (total left-sided hemicolectomy). A lower median laparotomy is performed with revision of the colon to clarify the nature and distribution of the pathological process. Using scissors, the outer layer of the peritoneum is cut at the root of the mesentery of the sigmoid colon along the left lateral canal, extending the incision down to the rectum and upward to the splenic flexure of the transverse colon. The diaphragmatic-colic ligament and part of the gastrocolic ligament are dissected. At the root of the mesentery of the sigmoid colon in the retroperitoneal space, the ureter is exposed, which is retracted outward. The internal layer of the peritoneum is dissected at the root of the mesentery of the sigmoid colon, where the inferior mesenteric artery and its branches are exposed. In case of incomplete hemicolectomy, the inferior mesenteric artery is preserved, and only the superior sigmoid arteries (except the inferior) and the left colic artery at their origin from the inferior mesenteric artery are crossed between the clamps and ligated. In a complete left hemicolectomy, the inferior mesenteric artery is divided between clamps at its origin from the aorta. During hemicolectomy for cancer in order to prevent hematogenous metastasis, it is advisable to first ligate the indicated vessels along their length before mobilizing the intestine. The next stage of the operation is the mobilization of the left flexure of the colon and the left third of the transverse colon. To do this, the diaphragmatic-colic ligament and then the gastrocolic ligament are crossed between the clamps and ligated until middle third transverse colon, preserving the vessels of the greater curvature of the stomach. When isolating the left flexure, care must be taken not to damage the vessels of the spleen and tail of the pancreas. The greater omentum is cut off with scissors to the level of resection of the left third of the transverse colon with ligation of the vessels. After mobilizing the sigmoid colon, descending colon and left flexure with the left third of the transverse colon, the sufficiency of blood supply to the remaining upper and lower segments of the colon is checked. Within well-supplied areas, intestinal clamps are applied to the left third of the transverse colon (closer to the left bend) and to the mobilized segment of the sigmoid colon or rectosigmoid section (hard clamps on the removed part, soft clamps on the remaining ends of the intestine). The intestine is crossed between the clamps and removed along with the retroperitoneal tissue. Next, the end of the transverse colon is brought down and a transversosigmoid (or transversorectal) end-to-end anastomosis is applied according to the usual technique. After anastomosis, the edges of the mesentery are sutured and the integrity of the peritoneum of the left lateral canal is restored. A drainage tube with one or two side holes is brought to the anastomosis area, which is removed through an incision in the left lumbar region and fixed to the skin.
Resection of the small intestine is a complex surgical procedure. Its essence is to remove a certain part internal organ, due to which there is indigestion. Excision of a section of the small intestine is prescribed for tumors (benign and malignant), vascular thrombosis, vascular strangulation and wounds. The length of the internal organ may differ for each person, which is why doctors consider the procedure of excision of intestine more than 1.5 meters dangerous.
Indications and reasons for resection
Resection of the small intestine is an urgent surgical intervention, which is prescribed by a doctor in case of obstruction, thrombosis and detection of tumors. If a patient has a large section of intestine excised, then after the procedure for 1-2 days the patient suffers from frequent bowel movements, which returns to normal after work is restored digestive system. After the operation, a person may become unable to work, and even dietary nutrition will not be able to put the patient “on his feet.” According to statistics, people after resection live 5-10 years less.
Excision of the small intestine is carried out in the most extreme cases, when other therapeutic methods are not able to cure a person.
The main reasons for surgery are: peptic ulcer stomach or bleeding, tumor-like neoplasms found in small intestine precancerous polyps, chronic inflammatory disease gastrointestinal tract, obstruction, trauma to the abdominal cavity, as a result of which the intestine was mechanically injured.
Features of preparation for surgery
Before prescribing a resection, the doctor must perform visual inspection, look at your medical history. The specialist will refer the patient to laboratory research urine and blood. Also to confirm the need surgical intervention need to get X-ray results chest and belly.
If necessary, magnetic resonance imaging (MRI), electrocardiography (ECG), can be performed. Sometimes the patient is sent to lab tests aimed at assessing liver function.
Research results and a comprehensive diagnosis of the human body allow the doctor to identify problems in the patient’s intestines and prescribe a course of treatment.
Both the doctor and the patient should prepare for surgery. The patient must adhere the following recommendations specialist: a week before surgery, you are prohibited from taking medications ( acetylsalicylic acid, drugs with anti-inflammatory and blood thinning effects).
You need to take antibiotics prescribed by the doctor 3-4 days before the procedure. You should also cleanse your colon with an enema or laxatives. medicines, and a week before surgery, start following a diet; it is advisable to exclude from the diet foods that contain.
About the technique of small intestine resection
Excision is done under general anesthesia so that the person does not feel pain and undergoes the operation more easily. There are 2 methods of performing the procedure: the first is open (the abdomen is completely cut), the second is laparoscopic (the specialist makes several small incisions into which cameras, light and the necessary sterile instruments are inserted).
The first method is classic and is rarely used. The second method of resection of the small intestine is new; it leaves no scars or scars. Other advantages include: minimal risk of infection, much shorter postoperative period, less painful recovery process.
Step-by-step laparoscopic surgery:
- the patient is given intravenous anesthesia and other sedatives;
- A large needle is inserted into the abdomen and the abdomen is filled through it. carbon dioxide(this is necessary so that the abdominal cavity increases and the procedure is easier to carry out);
- the specialist makes 4 to 6 incisions in the abdomen (a camera with an illuminating flashlight is inserted into one of the holes, and instruments are inserted into the others, for example, clamps, a scalpel and scissors);
- a section of the injured intestine is cut off, the resulting ends are stitched with a needle and thread or connected with special staples;
- the cut areas are lubricated with iodonate;
- All instruments are removed, gas is pumped out, incisions are sutured and a sterile dressing is applied.
The surgical intervention lasts from 2 to 3 hours. It happens that during the operation the surgeon can switch from laparoscopy to open (classical) resection.
Features of the procedure with the junction of the intestines “end to end” and “side to side”
End-to-end anastomosis is a classic surgical procedure and has the following stages: the patient lies on his back and finds a comfortable position, and is given anesthesia. Next, a probe is inserted through the stomach, an incision is made in the abdomen and an autopsy is performed (the main thing is not to touch the navel).
The specialist mobilizes the area of the diseased small intestine. The surgeon makes excisions as close as possible to the damaged intestine and vessels, while small vessels must be tied with thread.
To perform an anastomosis, the diseased intestine should be retracted to the side, and then the incision should be sutured with treble thread using the Lambert method (the surgeon's technique reduces tension in the cut areas).
In a side-to-side anastomosis, after dividing the intestine, the ends should be clamped together using a continuous turning suture. When the surgeon removes the clamps, the sutures are pulled tighter to prevent bleeding and blockage.
The specialist must ensure that blood circulation is not impaired; to do this, the outer suture stretches the edge of the mesentery. The walls are cut with a knife or scalpel, then they are separated with scissors. The mesentery is approached by silk sutures in the form of knots.
Postoperative care
After surgery in the hospital, the patient must be given an intravenous injection of lactated Ringer's solution, which replenishes the lack of fluid in the body. The patient is prescribed antibiotics. Even before the procedure begins, a catheter is attached to him, through which urine will be removed after surgery.
Decompression will be carried out for several days after resection; its essence is to suction fluid from the stomach. Decompression is needed until the small intestine has recovered.
After the patient has been discharged from the hospital, he must go for an examination to the attending doctor.
Issues related to physical activity, usual routine and lifestyle, driving vehicles, taking a bath and shower (in the first 2-3 days after resection, sutures should not be wetted with water), performing special exercises to prevent thrombosis of the lower extremities.
You can switch to a natural (habitual) diet 5-6 months after excision of the small intestine. After surgery, there is a risk of the following symptoms: fever, separation of staples or sutures, redness and swelling of the sutures, discharge from the sutures, constipation or diarrhea, pain syndrome in the abdominal cavity, nausea, vomiting.
If you have rectal bleeding, cough or chest pain, frequent urge to urinate, blood in your urine, or abdominal discomfort, seek immediate medical attention.
During the postoperative period, the patient goes on a strict diet. Many foods are prohibited from being eaten: fatty and fried foods, legumes, foods that bloat the stomach, some fruits (,). You can't drink carbonated water. It is recommended to refuse bad habits such as smoking and drinking alcoholic beverages. The patient needs to visit the doctor regularly and report how he is feeling. Period full recovery most often it takes from 6-9 months to 1-2 years.
About bowel resection
Briefly about the treatment method
Bowel resection is an operation to remove part of the small or large intestine. This is a fairly traumatic procedure, so it is not performed without very compelling reasons.
Types of bowel resection
Various types of resection are performed to remove various parts intestines. Each type of bowel resection is named based on what it removes:
Segmental resection of the small intestine: part of the small intestine is removed. The surgeon may also remove part of the mesentery (the fold of tissue that supports the small intestine) and The lymph nodes in this district. This type is used to remove tumors in the lower duodenum (upper part of the small intestine), jejunum (middle part of the small intestine), or ileum (lower part of the small intestine).
Right hemicolectomy: part of the ileum, the cecum (part of the large intestine), the ascending colon (part of the large intestine), the hepatic flexure (the flexure of the colon), the first part of the transverse colon (the middle of the large intestine), the appendix are removed.
Transverse colectomy: The transverse colon, hepatic and splenic flexures are removed. This surgery may be used to remove a tumor in the middle of the colon when the cancer has not spread to other parts of the colon.
Left hemicolectomy: part of the transverse and descending colon, the splenic flexure (the bend in the colon near the spleen), and part or all of the sigmoid colon are removed.
Sigmoid colectomy: The sigmoid colon is removed.
Low anterior resection: The sigmoid colon and part of the rectum are removed.
Proctocomectomy with ileoanal anastomosis: The entire rectum and part of the sigmoid colon are removed. An ileoanal anastomosis is a procedure that a surgeon does to attach the lower portion of the small intestine to the anus.
Abdomino-perineal resection: The rectum, anus, anal sphincter and muscles around the anus are removed. The surgeon makes one cut or incision in the abdomen and another in the perineum (the area between the anus and vulva in women or between the anus and scrotum in men). This procedure requires a permanent colostomy (taking a section of the colon out) because the anal sphincter is removed.
Partial and complete colectomy: surgery to remove part or all of the colon (including the cecum).
Indications and contraindications
Bowel resection is performed to treat the following diseases:- Cancer in the small intestine, colon, rectum, or anus;
- Cancer that has spread to the intestines (treatment and symptom relief);
- Blockage in the intestines (intestinal obstruction);
- Precancerous polyps before they become cancer (called preventative surgery);
- Inflammatory bowel disease or diverticulitis;
- Ulcerative colitis (characterized by chronic inflammation colon and rectum, resulting in bloody diarrhea). Surgery may be indicated when drug therapy does not improve the condition.
- Mesenteric thrombosis or abdominal ischemia;
- Intestinal necrosis.
The reasons for resection are always carefully assessed by the attending physician.
There are a number of contraindications for the operation:
- critical condition of the patient, leading to the inappropriateness of resection,
- coma or unconsciousness of the patient,
- pathology of the heart, kidneys or respiratory system, which can lead to serious complications during or after surgery,
- inoperable tumor.
Preparing for treatment
Before surgery, diagnostic tests are usually performed to check your general health and ensure that the surgery can be performed. This may include blood sampling, chest x-ray, electrocardiogram (ECG), angiography, CT or ultrasound, or endoscopy.You should follow a diet that excludes legumes, baked goods, alcohol, fresh fruits and vegetables. A liquid diet is administered at least the day before surgery, with nothing taken on the day of surgery.
Depending on the type of bowel resection, it may be necessary to cleanse the bowel. This usually involves taking a laxative 1-2 days before surgery. Cleansing enemas may also be given in the hospital.
Immediately before the procedure, antibiotics are prescribed to help prevent infection.
You should also tell your doctor about all the medications, supplements, and herbal products you take.
Anesthesia
Bowel resection is performed in the hospital under general anesthesia.How is the treatment carried out?
The surgeon may use open or laparoscopic techniques.
At open technology(laparotomy) the surgeon makes a large longitudinal incision to reach the intestine. In the laparoscopic technique, small holes are made in the abdomen, and then an endoscope (a thin, tubular instrument with a light and lens) and instruments are inserted to perform the operation. Laparoscopic techniques tend to shorten hospital stays, more fast time recovery, fewer complications and less pain during incisions. However, not all patients can undergo laparoscopic bowel resection due to the location and stage of the disease or other factors. In addition, surgeons require specialized training, skills, and equipment to use laparoscopic techniques.
The surgeon examines the cavity and removes the diseased or damaged part of the intestine within healthy tissue. However, some healthy tissue on either side of the affected part may also be removed.
Anastasmosis
When part of the intestine is removed, the surgeon connects the remaining ends of the intestine together using stitches or staples. This procedure is called anastomosis. When the entire large intestine is removed and the anastomosis is between the small intestine and the anus, it is called an ileoanal anastomosis. When he's between sigmoid colon and anus, it is called coloanal anastomosis. For any of these procedures, the surgeon may create a pocket before attaching the intestine to the anus. The pocket creates a place for stool when the rectum is removed. It helps reduce the number of bowel movements a person has and manage incontinence (the inability to control bowel movements).
In some cases, the surgeon does not connect the ends of the intestine together. Instead, it attaches one or both ends of the intestines to an opening in the abdomen. This procedure is called a colostomy or ileostomy (depending on the part of the intestine used) and is an artificial anus. A colostomy can be temporary or permanent.
Possible complications
The side effects that may occur depend mainly on the type of bowel resection and general condition health. They include:- obstruction (obstruction) of the intestine,
- paralyzed or inactive bowel
- damage to nearby organs such as bladder, ureter or spleen, anastomotic leak associated with infectious problems,
- excessive bleeding wound infection,
- hernia,
- thrombophlebitis,
- inability to control urination.
Forecast
The period of time required for recovery varies depending on the initial condition, type of resection, the patient's general health prior to surgery, and the length of bowel removed.The prognosis of bowel resection depends on the severity of the disease. For example, in the case of patients with ulcerative colitis, the disease is cured and most people go on to live normal, active lives. Patients with cancer will have a less positive prognosis (due to possible relapses).
Alternatives for bowel resection depend on the specific medical condition which is being treated.
Observation after treatment
After your bowel resection you will need to stay in the hospital for several days. The patient should be given warm, liquid food for 1-2 days after surgery. Solid foods and meals will be introduced gradually.If a colostomy or ileostomy has been performed, a specially trained health care professional will teach the patient how to care for themselves. Temporary ostomies usually remain in place for several months. After the rest of the colon has healed, another operation, an anastomosis, will be performed. The hole in the stomach will be closed.
A nasogastric tube is inserted through the nose into the stomach during surgery and may be left in place for 24 to 48 hours after surgery. This eliminates stomach secretions and prevents nausea and vomiting. It will remain until bowel activity resumes.
Postoperative patient care also includes monitoring blood pressure, pulse, respiration and temperature. Fluid intake and output are measured, and the color and amount of drainage from the wound is observed at the incision site.
The patient can get out of bed approximately 8-24 hours after surgery. Most patients will stay in the hospital for 5-7 days, although laparoscopic surgery can reduce this stay to 2-3 days.
Postoperative weight loss accompanies almost all bowel resections. Weight and strength are slowly restored over several months.
You will need to follow a diet prescribed by your doctor.
Full recovery from surgery may take two months. Laparoscopic surgery can reduce this time to one to two weeks.
Resection or excision of a section of the small intestine is performed in case of injury, necrosis in cases of vascular strangulation and thrombosis, and tumors.
Operation technique. The section of intestine to be removed is removed into the wound and covered with gauze. The boundaries of resection should be within the colon not involved in pathological process. The section of intestine to be removed is cut off from the mesentery. When resection of a small area, it is separated from the mesentery near the edge of the intestine. With the removal of a significant portion of the intestine, the part of the mesentery belonging to it should also be removed, excising it at an angle to the root of the mesentery. Dissection of the mesentery is performed between clamps applied to its vessels or tied threads brought under the vessels using a Deschamps needle. The area of intestine to be removed is clamped with intestinal clamps. The surgeon's further technique depends on the choice of the anastomosis created.
Anastomosis or anastomosis end to end(end-to-end). Soft intestinal clamps are applied obliquely to the length of the organ, outside the affected area of the intestine. In this case, 2 clamps are installed on each side of the resected segment of the intestine at intervals of 1.5-2 cm. A section of the intestine is cut off using the central clamps. The oblique position of the terminals makes the diameter of the intestine at the site of section wider, which subsequently prevents the narrowing of the digestive tube that occurs from the layering of anastomotic sutures. Peripheral clamps with the ends of the intestine are brought to each other, preventing twisting of the intestine. Holders - interrupted sutures, picking up the wall of both ends of the intestine through the mesenteric and free edges of the intestine, strengthen the position of the anastomosis. A serous-muscular suture is placed from holder to holder, grasping the walls of the ends of the intestine 3 mm below the edges of the inner lips of the anastomosis. Then a continuous suture is applied through the entire thickness of the wall of the inner lips of the anastomosis, which then passes into the Schmiden screw-in suture for the outer lips of the anastomosis. Remove the terminals from the intestine, check the patency of the anastomosis, change sterile napkins, and the surgeon washes his hands. By continuing the seromuscular suture that closes the screw-in suture, the creation of the anastomosis is completed. The defect in the mesentery is sutured with rare interrupted sutures. Rana abdominal wall sew up in layers.
Rice. 152. Resection of the small intestine. Technique for ligation of mesenteric vessels.
I - clamping of the mesentery and its intersection; II - application of a ligature to the area with crossed vessels; III - stages of excision of a section of intestine. Immersion of the intestinal stump into a purse-string suture.
Side to side anastomosis(Fig. 153) (side-to-side). Outside the affected area, the intestine is clamped with crushing clamps at right angles to its length. In place of the removed clamps, ligatures are applied, which, when tied, block the intestinal lumen. At a distance of 1.5 cm to the periphery from these ligatures, a seromuscular purse-string suture is applied. A soft clamp is applied inward from the tied thread and the intestine is crossed along it. The resulting intestinal stump is lubricated with iodine tincture and immersed with a purse string suture, which is tightened over it. Interrupted seromuscular sutures are placed on top. The other end of the intestine is treated in the same way. Curved soft clamps are applied to the central and peripheral blind ends of the intestine along their free edge and brought to each other isoperistaltically, i.e., along the course of peristalsis. The intestinal stumps are brought together with holders at intervals of 8-9 cm. A seromuscular suture is applied from one holder to the other. At both ends of the intestine, incisions are made to open the intestinal lumen, following 0.5-0.75 cm indentation and parallel to the serous-muscular suture. These incisions should end 1 cm short of the beginning and end of the suture. The inner lips of the anastomosis are sutured with an Albert suture, and the outer lips with a Schmieden suture. After changing the napkins and washing your hands, remove the clamps and make the final seromuscular suture. The hole in the mesentery is closed with several sutures. The abdominal wall wound is sutured in layers. Side-to-side anastomosis is somewhat easier to perform than end-to-end, and less often leads to a narrowing of the intestinal lumen.
Rice. 153. Resection of the small intestine with side-to-side anastomosis.
a - the first clean interrupted sutures according to Lambert; b - opening of the lumens of both connected intestinal loops; 1 - front (outer) lips; 2 - rear (inner) lips; c - suturing the posterior lips with a continuous encircling suture; d - suturing the anterior lips with a continuous screw-in Schmieden suture; d - application of a second clean interrupted suture according to Lambert.
