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Segmental jejunal resection with side-to-side anastomosis - general and visceral surgery
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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
Exteriorizing the small intestine
Determining the resection margins
Dividing the mesentery
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
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
Incising the ends of the intestine
Suturing the posterior wall
Suturing the anterior wall, completing the anastomosis
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
Closing the mesenteric window
Reducing the anastomosis
Closing the laparotomy
Completing the operation