Segmental jejunal resection with side-to-side anastomosis

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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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