Perioperative management - Jejunal segment resection with side-to-side anastomosis

• Small bowel stenosis due to tumor or extensive scar stenosis.
• In severe dissection-related injuries of the small intestine that cannot be managed by oversewing and therefore require a small bowel resection.
• For exclusion of a small intestine segment for an ileal conduit for urinary diversion and restoration of continuity.
• After small bowel resections due to ischemia.
• In small bowel resections due to involvement in a tumor located elsewhere or similar.

• Even after small bowel segment resections, an anastomosis can be critical with regard to healing: e.g., in very difficult perfusion conditions or the most severe comorbidity of the patient, such as septic shock.
• In these cases, a stoma creation should be considered and possibly more sensible, in order not to risk an anastomotic insufficiency!

• For tumors, cross-sectional imaging with computed tomography or MRI is indicated.
• For chronic inflammatory bowel diseases, small bowel imaging using MRI-Sellink is the optimal standard today.
• In exceptional cases, a simple contrast medium representation using a water-soluble contrast medium can be performed (relatively inaccurate examination, in ileus the contrast medium dams up before a stenosis without leading to a meaningful statement).
• in individual cases, double-balloon endoscopy or capsule endoscopy can be performed, particularly to clarify endoluminal findings.

• A special preoperative therapy or preparation is not necessary:
• In general, it is sufficient to keep the patient fasting overnight, as the small intestine empties within the shortest time.
• A lavage with saline or other laxatives is common, but according to recent data, not useful!

• General surgical risks

In addition:

1. Risk of anastomotic insufficiency.
2. After extensive small bowel resections – particularly in the terminal ileum – attention should be drawn to the possibility that permanent substitution of vitamin B12, fat-soluble vitamins, and calcium may become necessary!
3. For planned extensive resections, note the possibility of short bowel syndrome!

• By default, general anesthesia is performed for a small intestine procedure.
• Since the small intestine is very mobile, it can be brought in front of the abdominal wall through very small incisions, inspected, and if necessary, resected and anastomosed.
• Consequently, accompanying measures such as an epidural catheter are generally not required!
• The postoperative analgesia can be carried out using the usual analgesia with non-steroidal anti-inflammatory drugs and opioids.
• If an epidural catheter has nevertheless been placed, it can of course be used postoperatively for pain therapy.

• By default, the patient is positioned on the back
• Abduction of both arms

• By default, the surgeon stands to the right of the patient, with the first and second assistants opposite him.
• In some cases, the second assistant can also stand to the left next to the surgeon.
• The scrub nurse is located on the left side of the patient and stands to the left of the first assistant. The instrument table is usually positioned so that the instruments on the table can be placed at the height of the patient's thighs or hips.

As a rule, a retractor or frame that is standardly used for abdominal operations is employed.
Different systems are available and commonly used here.

Postoperative Analgesia:
Adequate pain therapy; for stronger pain, additionally a morphine analog (e.g. Targin® 1 – 2x 7.5 mg/d); please follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) or follow the link to the current guideline Treatment of acute perioperative and posttraumatic pain.

Medical Follow-up Care:
In any case, if there is no backlog, the gastric tube can be removed at the latest on the 1st postoperative day; removal of the skin suture material around the 10th postoperative day.
Thrombosis Prophylaxis:
The standards apply here with regard to prophylaxis, which should be carried out with a low-molecular-weight heparin! Please follow the link to the current guideline Prophylaxis of venous thromboembolism (VTE).

Mobilization:
At least to the edge of the bed on the day of surgery; ideally, the patient is mobilized to the chair in the room and also in the hallway on the day of surgery. This is continued in the time after the operation. Depending on the size of the laparotomy, intensive respiratory therapy with appropriate devices should be carried out!
Physiotherapy:
If necessary, respiratory and bed exercises.
Diet Build-up:
The diet build-up is handled somewhat differently depending on the height of the anastomosis. In any case, if there is no backlog, the gastric tube can be removed at the latest on the 1st postoperative day and the diet build-up can begin with liquid food, i.e. tea and soup. The further diet build-up is then oriented to the patient's symptoms. I.e. provided that belching, vomiting or nausea do not occur and – from the clinical examination – the abdomen remains soft, the diet build-up can be continued on the 2nd/3rd day via pureed food to solid food that must be chewed well.
Bowel Regulation:
Bowel movement should usually start by the 3rd day. If this is not the case, treatment can be carried out with the usual laxatives. These include, for example, the administration of magnesium in the morning and evening, Laxoberal or Prostigmin, which can be administered subcutaneously or i.v.
Inability to Work:
Depending on the size of the procedure and the comorbidity, a hospital stay of at least 5 – 7 days is to be expected. 
The inability to work will be certified for at least 1 – 2 weeks after the hospital stay, depending on the patient's workload.
The latter is subject to very large individual variations – depending on the patient's personality and occupation.