Small bowel resection and anastomosis

Small bowel resection and anastomosis is widely used in clinical practice. Although there is no difference in the operation of the intestine segment, the prognosis is very different. Therefore, it is necessary to correctly determine which part of the resection should be performed during the operation, and it is appropriate to remove it; especially the large intestine resection must be treated with caution. Secondly, according to different situations, appropriate matching methods should be selected to achieve better results. Treatment of diseases: small intestine rupture small intestine tumor Indication 1. Intestinal necrosis of small intestine caused by various reasons, such as strangulated hernia, intestinal torsion, intussusception, mesenteric trauma and so on. 2. Severe extensive injury of the small intestine, repairing difficulties. 3. Intestinal inflammatory ulcers produce perforation, local tissue inflammatory edema and are fragile, and cannot be repaired or repaired unreliable. 4. Congenital malformations of the intestine (such as stenosis, atresia); or local intestinal stenosis caused by intestinal tuberculosis or segmental enteritis; or multiple hernias in the intestinal fistula. 5. Small intestine tumors. 6. Some small intestines are widely adhered into a mass, leading to obstruction, unable to be separated, or although separated, but the muscle wall of the intestinal wall is more severely damaged, the intestinal wall is thin, and the viability is unreliable. 7. Complex intestinal fistula. Preoperative preparation Patients requiring small bowel resection and anastomosis are often accompanied by water, electrolyte imbalance, malnutrition, anemia, or toxic shock. The necessary preparations must be made for specific situations. 1. Intravenous saline, Ringer's solution, 5% to 10% glucose water, etc., to correct dehydration and electrolyte imbalance. 2. Patients with anemia, malnutrition, and shock should be corrected by appropriate blood transfusion or plasma. 3. Patients with severe signs of systemic infection, given antibiotics, usually penicillin, streptomycin, chloramphenicol, gentamicin, cephalosporin and metronidazole intramuscular or intravenous drip. In addition, elective surgery patients with oral administration of neomycin, streptomycin or metronidazole 1 to 3 days before surgery can reduce bacteria in the intestines. 4. People with chronic malnutrition should be given a variety of vitamins. 5. Preoperative gastrointestinal decompression, this point is especially important for patients with intestinal obstruction. 6. Preoperative enema. If the operation involves the colon, it should be used as a cleansing enema. Surgical procedure 1. Position: supine position, slightly separated lower limbs. 2. Incision: often use the right side of the right side incision, about 8 ~ 10cm long, 1/3 is located on the umbilicus, 2 / 3 is located under the umbilicus, the rectus abdominis muscle is pulled outward. If the lesion is determined to be on the left side before surgery, the left side median incision is made. 3. Exploration: According to the condition, the exploration of the intra-abdominal organs should be carried out to further confirm the diagnosis, and the extent of the intestine to be removed should be determined, and the incision should be carefully placed outside the incision. It is usually cut at 3 to 5 cm from the proximal and distal ends of the lesion. If the intestinal necrosis caused by intestinal obstruction, the scope of proximal resection should be slightly more. In the case of malignant tumors, extensive excision of regional lymph nodes should be included, and the intestines of the cut-off section must be normal. 4. Protect the incision and abdominal cavity: Lift the diseased intestine outside the incision, and separate it between the intestine and the abdominal wall with a warm saline gauze pad; then place two dry sterile gauze under the gauze pad to separate it from the incision. It can reduce the damage of the small intestine and prevent the intestinal contents from contaminating the abdominal cavity. 5. Treatment of mesenteric vessels: A gap is separated on both sides of the main mesenteric vessels supplying the resected segment to fully expose the blood vessels. Use two curved hemostat clamps (the distance between the two clamps is 0.5-0.6 cm), cut the blood vessel between the clamps, cut off the distal end, and ligature the distal end with the 1-0 silk thread, then ligature the proximal end. After the first ligation, do not loosen the proximal hemostasis, and on the far side of the ligature, use the No. 0 wire for the squat or 8-slot. Then, the mesentery is cut off by a fan shape. When it is difficult to distinguish blood vessels, such as patients with more fat, they can be clamped and cut after the light is swallowed under the light. 6. Resection of the intestine: Before cutting the intestine, the mesentery of both ends of the intestine should be separated from each other by 0.5 cm. Check again to preserve the blood supply to the intestine. Use a straight hemostat to clamp the two ends of the intestine to be resected. The tip is oriented toward the mesentery and is inclined at an angle of about 30° to the longitudinal axis of the intestine (inclination to the reserved side) to increase the anastomosis and to ensure blood flow to the anastomosis. Then use the intestinal clamp to clamp the intestine at a distance of 3 to 5 cm from the margin. It should not be clamped too tightly, so it is better to block the outflow of the intestinal contents. The intestines are removed by a straight hemostatic forceps at both ends, and the removed intestines are wrapped with a sterile towel or placed in a basin and then removed. Absorb the contents of the broken end and wipe it with a "small fish" gauze, then wipe the intestinal mucosa with 2% red mercury solution or 1:1000 benzalkonium. 7. Anastomotic intestine: There are several types of anastomosis, such as end-to-end anastomosis, lateral anastomosis, and end-to-side anastomosis. In general, end-to-end anastomosis should be used. (1) End-end anastomosis: Close the two intestinal clamps and check if the anastomosis of the intestines is twisted. The upper and lower intestines of the intestines were sutured from the mesangial side of the intestine with a fine silk thread for suture. Care should be taken to close the triangular area of the mesenteric margin without peritoneal coverage. A needle is also sewn on the opposite side edge, and the two needles are clamped by the hemostat as a traction, and no ligation is allowed. The posterior wall of the anastomosis was sutured with a full-thickness suture of No. 0, and the needle spacing was generally 0.3 cm to 0.5 cm. Then, the traction lines on both sides of the intestine are ligated. Then suture the anterior wall of the anastomosis, the needle is inserted into the needle from the mucosa at one end, and after the serosa is penetrated, the needle is inserted into the mucosa from the opposite serosa, so that the knot is hit in the intestinal lumen, and the intestinal wall is inverted. The inner layer is stitched. The intestinal clamp was removed and the outer layer (second layer) was sutured. The suture of the muscle layer is made by the thin wire, the needle spacing is 0.3cm~0.5cm, and the needle is about 0.3cm away from the suture of the first layer, so as to avoid excessive varus, forming a valve and affecting the passage. After the anterior wall pulp muscle layer was sutured, the intestine tube was inverted and the wall muscle layer was sutured. Note that the mesenteric side and the mesenteric side of the intestine should be aligned and closed. If necessary, 1 to 2 needles can be reinforced at this point, and the end-to-end anastomosis is completed. Gently squeeze the two ends of the intestine by hand to observe whether there is leakage in the anastomosis and fill in the number of needles if necessary. Use the thumb and forefinger fingertips to check the anastomosis for stenosis. Remove the surrounding disinfectant towel, replace the saline gauze pad, and take away the contaminated instruments that have been used for bowel resection and anastomosis. The operator washes gloves or replaces gloves. The mesenteric cutting edge is then sutured with a thin thread to eliminate the rough surface. Care should be taken to avoid blood vessels during suture to avoid bleeding, hematoma or blood supply to the intestine. Place the sutured intestines back into the abdominal cavity (be careful not to twist) and suture the abdominal wall incision layer by layer. (2) Lateral anastomosis: At present, except for the obstruction of the output segment after gastrointestinal anastomosis or the lateral anastomosis after esophageal jejunostomy, the lateral side is only used when the cause of obstruction cannot be removed or the patient is not allowed to undergo intestinal resection. Match. Because the lateral anastomosis does not conform to the peristaltic function of the normal intestinal canal, the anastomosis is substantially closed in the absence of contents in the intestinal canal. Since the circumflex muscles are cut at both ends, the peristaltic function of the anastomosis segment is greatly reduced, and the emptying function is incomplete. When the contents of the intestines descend, they tend to impact the stump first, causing strong peristalsis after being blocked, and then returning from the stump, and then running down through the anastomosis. After a long period of time, cystic dilatation is often formed at both ends of the intestinal tube, and further development can form a fecal mass (block) obstruction or cause intestinal perforation, intestinal fistula, etc., that is, the so-called blind wart syndrome. Patients often suffer from anemia and malnutrition after surgery, often with abdominal pain, diarrhea and other symptoms, and long-term effects are poor. For bowel resection, the distal and proximal fractures should be sutured with a full-thickness continuous suture plus sarcolemma suture, and then the lateral anastomosis. The method of anastomosis is to first clamp the two segments of the intestine tube selected for anastomosis with the intestinal clamp so as not to cut the intestinal wall to overflow the intestinal contents. After placing the two clamps side by side, the two sections of the intestinal wall were sutured in a row of fine silk serosal muscle layers, about 6 cm in length, about 0.5 cm from the opposite side of the midline of the mesangium. After being protected with a gauze pad, each side of the suture (i.e., the midline of the two sides of the intestine wall) was cut to a length of about 5 cm. Suck the intestine contents of the incision, clamp and ligature the bleeding point. Use the 1-0 gut line from the end of the incision as the posterior wall of the anastomosis and suture the whole layer (the knot is in the intestine), then turn to the anterior wall of the anastomosis for a full-layer continuous inversion suture, two The ends of the ends are knotted and the inner layer of the anastomosis is sutured. After removing the intestinal clamp, the anterior wall of the anastomosis was sutured as a row of sarcolemma. If there are loopholes in the examination, the needle should be repaired and the needles can be added at both ends of the anastomosis. After the anastomosis is completed, use your fingers to check if the size of the anastomosis meets the requirements. (3) end-to-side anastomosis: end-to-side anastomosis is generally used for anastomosis when the upper and lower cavities of the intestine are very different, or when the cause of intestinal obstruction cannot be removed, it is necessary to be a shortcut surgery, and various y-shaped anastomosis. The anastomosis should be close to the distal end of the intestine, otherwise it may cause blindness syndrome. But now this method of anastomosis has been used less clinically. For example, the ileum-transverse colonic end-to-side anastomosis is performed: the cut-off is prepared at the end of the ileum, and the mesentery is separated from the mesenteric root, ligation and hemostasis. At the proximal end of the intestine clamp, the distal end of the clip is clamped to the hemostat, and the gauze pad is used to protect the intestine. After resection of the right colon, the resected end of the colon was sutured with a continuous laparoscopic suture with a full-thickness suture. After the proximal ileum was disinfected, the end of the transverse colon was double-stitched with an end-to-side anastomosis. The suture method was the same as the end-end anastomosis. Finally, the mesenteric rupture is closed.

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