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