Segmental jejunal resection with side-to-side anastomosis

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  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Surgically relevant anatomy

    • The jejunum is the second of three sections of the small intestine. It extends from the duodenum to the ileum.
    • Its colloquial German term of “Leerdarm” or “empty bowel” stems from the fact that in most dead patients it is empty.*

    The jejunum is plicated in numerous loops and with its mesentery attaches to the posterior abdominal wall. The corresponding segment of the mesentery is called mesojejunum. When considered together with the ileum, which begins at the jejunum and terminates at the cecum, the radix mesenterii or root of the mesentery extends from the duodenojejunal flexure to the ileocecal valve.

    • Since the loops of the jejunum are quite mobile, they shift their positions. While the beginning of the jejunum is well defined by the duodenojejunal flexure at the level of the second lumbar vertebra, the boundary between the jejunum and ileum is not so evident.
    • Like any other hollow viscus, the jejunum is lined with a mucous membrane (tunica mucosa). On the outside the mucous membrane is enclosed by a double layer of smooth muscle (tunica muscularis), while the serosa is a reflection of the peritoneum over the exterior of the jejunum.
    • The superior mesenteric artery supplying the jejunum, ileum, appendix, ascending colon and the proximal two thirds of the transverse colon courses in the proximal section of the mesenteric root.
    • The jejunal arteries are branches of the superior mesenteric artery and supply the jejunum with blood. The veins of the jejunum drain into the superior mesenteric vein which parallels the superior mesenteric artery on the right and then courses posterior to the head of the pancreas to the portal vein.
    • The jejunum is primarily innervated by the enteric nervous system. Peristalsis is controlled by the mesenteric plexus (Auerbach plexus), while the mucous membrane is innervated by the submucous plexus (Meissner plexus). In addition, the jejunum is also regulated by the sympathetic and parasympathetic nervous systems (in particular the vagus nerve).

    Ieiunus is Latin for fasting, hungry, meagre *

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • 7. Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative Management

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date of publication: 20.09.2009

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  • Skin incision

    75-3

    Small median laparotomy, depending on the location of the findings in the small intestine either superior, periumbilical or inferior to the umbilicus.

    It should be noted that laparotomies in the lower abdomen result in better cosmesis. The initial skin incision should be about 8 cm long. This usually suffices to exteriorize the small intestine but, if necessary, the skin incision can be extended. As a rule, any incision involving the umbilicus should skirt it on the left.

  • Toweling the skin edges

    75-4

    When an anastomosis is likely, it is advisable to first protect the edges of the skin with an incise drape or moist towel and insert the retractor afterward.

  • Exteriorizing the small intestine

    75-5

    The small intestine is exteriorized, and the lesion located. If possible, check the small intestine in its entirety, which should normally be possible via a correspondingly small surgical access, if there no adhesions.

  • Determining the resection margins

    75-6

    Now determine the margins of resection, e.g., by passing a plastic loop around them, which markedly facilitates handling and improves the view.

  • Dividing the mesentery

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    Now divide the mesentery between Overholt forceps. Ligate the mesentery distad to the dissection. Secure the centrad mesentery with ligatures or suture ligatures. Centrad care must be taken to ensure definite hemostasis; in case of doubt, it is better to employ one suture ligature too many than too little.

  • Preparing the side-to-side anastomosis

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    Particularly when facing a difference in lumen, as in the present case, it makes sense to perform a laterolateral anastomosis. The present patient not only demonstrates extensive metastasis in prostate cancer, but also stenotic primary cancer of the small intestine, as clearly evidenced by the dilated proximal intestinal loop. Due to the palliative situation with hopeless prognosis, surgery will be limited to a segmental resection. In case of a primary tumor to be managed with curative intent, the margins of the resection should be further apart and the mesentery with its lymph nodes would have to be excised far centrad. The side-to-side anastomosis is prepared by dividing the ends of the jejunal segment with a stapler. You can minimize cost by closing off the ends of the segment with manual sutures.

  • Suturing the staple line

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    While the staple lines at the ends of the intestines can be secured by inverting manual suture, this is not mandatory. The benefit of oversewing is its definitive hemostasis and that it helps prevent adhesions of the staple line with other structures in the abdominal cavity, e.g., intestinal loops.

  • Incising the ends of the intestine

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    Parallel the ends of the bowel so that side-by-side anastomosis can be planned. Then incise both ends of the intestine at their antimesenteric aspect.

  • Suturing the posterior wall

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    Start the anastomosis with a continuous monofilament suture of the posterior wall. We prefer a Maxon® suture 3/0 or 4/0.

  • Suturing the anterior wall, completing the anastomosis

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    Suture the anterior wall in the same direction. If possible, the surgeon should suture toward him-/herself or at least from left to right. Bidirectional sutures may be employed or – as in our case– use a second suture and tie it off with the first suture fashioning the posterior wall. After completion of the anterior wall – and after reaching the tied end of the first suture– tie both sutures together, thereby completing the anastomosis.

  • Checking the anastomosis

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  • Closing the mesenteric window

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  • Reducing the anastomosis

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  • Closing the laparotomy

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  • Completing the operation

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  • Intraoperative complications

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  • Postoperative complications

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  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Reviews

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  • Guidelines

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  • Guidelines

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  • literature search

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