Chapter 8.1

Chapter 8.1

Small Bowel Resection

Jeffrey W. Milsom, Bartholomäus Böhm, and Kiyokazu Nakajima

Indications

A laparoscopic small bowel resection with primary anastomosis is most frequently indicated for benign diseases. These would include isolated Crohn’s disease, gastrointestinal stromal tumors, benign strictures, and vascular malformations. Malignant conditions re- present relative contraindications in that they are rare and if diagnosed or suspected we do not believe laparoscopic methods have a defi ned role in their treatment. The conduct of the operation should be in a manner very similar to that of a conventional small bowel resection.

Patient Positioning and Operating Room Setup

The patient is placed supine in a modifi ed lithotomy position using Dan Allen stirrups. Surgery is begun in the Trendelenburg position (20° head-down tilt) and, after cannula insertion, the patient is tilted left side down for ileal surgery or the right side down for jejunal surgery.

The surgeon and assistants stand in a half circle opening toward the area of interest. Figure 8.1.1A shows the positions for ileal surgery.

After cannula insertion, the surgeon stands between the legs and both assistants stand on the left side of the patient for the remainder of the procedure. The scrub nurse should stand on the right side near the knee. One monitor is placed close to the patient’s right shoulder, the optimal position for viewing by the surgeon and assistants; the second monitor is placed near the left shoulder, the best location for viewing by the nurse. An alternative can be that one fl at screen monitor is used, which is placed above the patient’s head, for all members of the operative team to use (Figure 8.1.1B). For jejunal surgery, the setup is a mirror image of the ileal positions.

111

Figure 8.1.1. A Position of the equipment and the surgical team for ileal resection. B Alter- native positioning of the fl at screen monitor so that all team members may look at the same monitor suspended above the

patient’s head. B

112

Instruments

Specifi c instruments recommended for small bowel resection are listed in Table 8.1.1.

Cannula Positioning

Cannulas should be positioned in a half circle or line facing toward the site of pathology. Thus, for jejunal surgery, the half circle will open toward the right upper quadrant (Figure 8.1.2), whereas for ileal surgery, small bowel resection

3–5 Cannulae (1 ¥ 10 mm, 2–4 ¥ 5 mm)

1 Dissecting device (i.e., LigaSure V

or Ultrasonic Shears

or electrosurgery)

1 Laparoscopic scissor 1 Laparoscopic dissector 2 Laparoscopic graspers

Figure 8.1.2. Position of the cannulae for ileal resection. For jejunal surgery,

the left- and right-sided cannulae may suffi ce. For ileal surgery, it may be

preferable to use the suprapubic cannula and omit the right lower quadrant

one.

it will open toward the left upper quadrant. In many cases, only 2–3 cannulae are used to accomplish a diagnostic laparoscopy and to local- ize the pathology. A fourth cannula in the suprapubic area may be helpful in certain cases and should be placed readily if this may be helpful for retraction or exposure. Alternatively, for ileal surgery, the suprapubic cannula may be preferable and the right lower quadrant one may be eliminated.

Technique

Once the preoperative diagnosis is confi rmed and the laparoscopic procedure appears feasible, the pathology is located by running the entire length of the small bowel and placing a suture just upstream of the pathology.

Running the small bowel is accomplished from proximal to distal by placing the patient on the left side up, in slight reverse Trendelenburg position until the mid small bowel is reached, then adjusting the patient to the right side up with Trendelenburg position to run the distal half of the small intestine. The surgeon should start the “running” from between the legs then switch to the left side of the patient for the distal half (or permit the fi rst assistant to run the distal half from left side of the patient). The technique of “running” should be “hand-over-hand”

(Figure 8.1.3A and B) or “hand-to-hand” (Figure 8.1.4A–C) based on the degree of freedom present within the abdominal cavity.

If it will be advantageous to divide the mesenteric vessels before delivery of the specimen through the abdominal incision, this should be done using a LigaSure V

instrument. We currently would just ligate the main vessel supplying the affected segment, and leave the other vessels of the mesentery to be divided through the incision. This may be especially helpful in a patient with a thick abdominal wall.

Once the specimen is fully mobilized, a cannula site is enlarged to 3–5 cm. For small incisions, a transverse incision is preferred. The ante- rior rectus sheath is transversely incised, the rectus muscles retracted, and the posterior sheath also transversely incised. If the incision has to be larger because of a bulky tumor, a longitudinal incision in the midline is accomplished above and below the umbilicus.

The wound is protected using a plastic sheath and the loop of intes- tine to be resected is drawn out through the enlarged incision. Wound protection is important to reduce any contamination by tumor cells or intestine and it may also facilitate the specimen extraction. The resection and anastomosis are then made in a standard manner extracorporeally, either by a hand-sewn or stapled method. The mesenteric defect is usually closed with a running absorbable suture through the incision.

After performing the anastomosis, the abdomen is copiously irri-

gated with warm sterile saline solution through the incision. The fl uid

is removed by placing the patient in the head-up position and passing

a sump suction cannula into the pelvis. After irrigation of the peritoneal

cavity, the abdominal wall is closed with a running suture or a series

single suture.

Figure 8.1.3. Running the bowel using the “hand-over-hand” technique. A The right-handed grasper (1) releases the bowel and prepares to move from point A on the bowel to point C, while the left handed grasper (2), at point B, prepares to slide to the right of the illustration. B The instruments are crossed (hand- over-hand), and the left hand (2) now releases point B on the bowel and slides beneath the right-handed grasper (1) to regrasp at point D. Next the process repeats itself.

A

B

The peritoneal cavity can then be fi nally inspected laparoscopically

by leaving the wound protector in place, twisting it closed at the skin

level, then clamping it with a Kocher clamp (Figure 8.1.5). This

permits rapid reestablishment of the pneumoperitoneum, with a good

seal of the specimen extraction site, for a fi nal inspection inside the

abdomen.

A

B

C

Special Considerations

The most important steps of laparoscopically assisted small bowel surgery are to localize and mobilize the diseased segment and deliver it through a small incision. The technique has become our procedure of choice for isolated benign small diseases. We do not believe that an intracorporeal anastomosis should be attempted at this time because most of the dissection and anastomosis can safely be performed using conventional techniques through a small incision used to remove the specimen.

The role of this approach in cancer surgery is limited. If there is diffuse spread of the disease, then it may be reasonable to consider a laparoscopic localization of the tumor in order to minimize the incision, or to consider only biopsy and no resection. Because these are rare tumors, and there is no proof of the effi cacy of a laparoscopic approach, Figure 8.1.5. Twisting the wound protector and closing it with a clamp to quickly reestablish pneumoperitoneum after removing the specimen.

Figure 8.1.4. Running the bowel using the “hand-to-hand” technique: A The right-handed grasper (1) releases the bowel and moves down from A to B next to the left-handed grasper (2). B The left-handed grasper releases (2) then moves downstream from point B to C grasping the bowel there. C The process repeats itself, the right-handed grasper (1) releasing again and moving down (2) from B to C.

䉳

caution should be exercised before applying laparoscopic methods for

a resection. A laparoscopic-assisted approach could be considered,

which would include a careful inspection of the entire abdomen, includ-

ing the liver, then the umbilical cannula site enlarged in order to

perform the appropriate mesenteric and intestinal resection. Thus, the

actual resection would be done using conventional methods.