SMALL BOWEL RESECTION 2

Open small bowel resection
Following adequate bowel preparation, the patient is placed under general anesthesia and positioned for the operation. The surgeon starts the procedure by making a midline incision in the abdomen. The diseased part of the small intestine (ileum or duodenum or jejunum) is removed. The two healthy ends are either stapled or sewn back together, and the incision is closed. If it is necessary to spare the intestine from its normal digestive work while it heals, a temporary opening (stoma) of the intestine into the abdomen (ileostomy, duodenostomy, or jejunostomy) is made. The ostomy is later closed and repaired.

Laparoscopic small bowel resection
Laparoscopic small bowel resection features insertion of a thin telescope-like instrument called a laparoscope through a small incision made at the umbilicus (belly button). The laparoscope is connected to a small video camera unit that shows the operative site on video monitors located in the operating room. The abdomen is inflated with carbon dioxide gas to allow the surgeon a clear view of the operative area. Four to five additional small incisions are made in the abdomen for insertion of specialized surgical instruments that the surgeon uses to perform the surgery. The small bowel is clamped above and below the diseased section and this section is removed. The small bowel ends are reattached using staples or sutures. Following the procedure, the small incisions are closed with sutures or surgical tape.,

Diagnosis / Preparation
As with any surgery, the patient is required to sign a consent form. Details of the procedure are discussed with the patient, including goals, technique, and risks. Blood and urine tests, along with various imaging tests and an electrocardiogram (EKG), may be ordered as required. To prepare for the procedure, the patient is asked to completely clean the bowel and is placed on a low residue diet for several days prior to surgery. A liquid diet may be ordered for at least the day before surgery, with nothing taken by mouth after midnight.

Preoperative bowel preparation involving mechanical cleansing and administration of antibiotics before surgery is the standard practice. This involves the prescription of oral antibiotics (neomycin, erythromycin, or kanamycin sulfate) to decrease bacteria in the intestine and help prevent postoperative infection. A nasogastric tube is inserted through the nose into the stomach on the day of surgery or during surgery. This removes the gastric secretions and prevents nausea and vomiting. A urinary catheter (thin tube inserted into the bladder) may also be inserted to keep the bladder empty during surgery, giving more space in the surgical field and decreasing chances of accidental injury.

Aftercare
Once the surgery is completed, the patient is taken to a postoperative or recovery unit where a nurse monitors recovery and ensures that bandages are kept clean and dry. Mild pain at the incision site is commonly experienced and the treating physician usually prescribes pain medication. Postoperative care also involves monitoring of blood pressure, pulse, respiration, and temperature. Breathing tends to be shallow because of the effect of anesthesia and the patient’s reluctance to breathe deeply and experience pain that is caused by the abdominal incision.

The patient is given instruction on the way to support the operative site during deep breathing and coughing. Fluid intake and output is measured, and the operative site is observed for color and amount of wound drainage. The nasogastric tube remains in place, attached to low intermittent suction until bowel activity resumes. Fluids and electrolytes are infused intravenously until the patient’s diet can gradually be resumed, beginning with liquids and progressing to a regular diet as tolerated. The patient is generally out of bed approximately eight to 24 hours after surgery. Patients are usually scheduled for a follow-up examination within two weeks after surgery. During the first few days after surgery, physical activity is restricted.

Risks
Risks include all the risks associated with general anesthesia, namely, adverse reactions to medications and breathing problems. They also include the risks associated with any surgery, such as bleeding or infection. Additional risks associated specifically with bowel resection include:
• bulging through the incision (incisional hernia)
• narrowing (stricture) of the opening (stoma)
• blockage (obstruction) of the intestine from scar tissue.

Normal results
Complete healing is expected without complications after bowel resection, but the period of time required for recovery from the surgery varies depending on the condition requiring the procedure, the patient’s overall health status prior to surgery, and the length of bowel removed.

Morbidity and mortality rates
According to the National Cancer Institute, the predominant treatment for small intestine cancers is surgery when bowel resection is possible, and cure depends on the ability to completely remove the cancer. The overall five-year survival rate for resectable adenocarcinoma is 20%. The five-year survival rate for resectable leiomyosarcoma, the most common primary sarcoma of the small intestine, is approximately 50%. Crohn’s disease is a chronic incurable disease characterized by periods of progression and remission with 99% of patients suffering at least one relapse. Physicians are presently unable to predict the extent and severity of the disease over time; thus, while morbidity is very high for Crohn’s disease, mortality is essentially zero.

Alternatives
Alternatives to bowel resection depend on the specific medical condition being treated. For most conditions where bowel resection is advised, the only alternative is treatment with drugs.