Bowel Anastomosis

When is an intestinal resection indicated?

The operation may be required in the following cases:

· In cases of strangulation and gangrene of bowel

· Volvulus

· Intussusception (irreducible)

· Tuberculosis of intestine with stricture

· Intestinal fistula

· Regional enteritis

· Ulcerative colitis

· Tumour of intestines.

What are the types of anastomosis?

· End to end

· End to side

· Side to side

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BOWEL RESECTION Procedure 6

SMALL BOWEL RESECTION

Position of the patient

Suspine

Anaesthesia

General

Surgical steps

· Open the abdomen (paramedian) and gain entry to the peritoneal cavity.

· Identify the area to be resected.

· Divide mesentery to this area in the line of a shallow V, serially between ligatures.

· The apex of the V is towards the root of the mesentery.

· Divide bowel to be removed obliquely, removing more of antimesenteric border between non-crushing clamps.

· Approximate non-crushing clamps to appose the two cut ends of bowel.

· Carry out end-to-end anastomosis – an inner continuous layer of catgut and an outer continuous layer of silk.

· Approximate cut end of mesentery with interrupted sutures.

Instruments required

· Laparotomy set,1

· Allen intestinal clamps, 1 pair

When is an intestinal resection indicated?

The operation may be required in the following cases:

· In cases of strangulation and gangrene of bowel

· Volvulus

· Intussusception (irreducible)

· Tuberculosis of intestine with stricture

· Intestinal fistula

· Regional enteritis


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PROCEDURES 5 Jejunostomy

Jejunostomy

Objective

To provide a route for parenteral nutrition

Position

Supine

Anesthesia

General or local

Procedure

*locate a proximal loop of jejunum close to deudeno-jejunal flexure

 (DJ)

*Select a site 15-20 cm from DJ

*Through a stab wound on antimesenteric border introduce a carheter

 14F foley

*Close the opening around the catheter with catgut suture

*Bury the catheter in a short tunnel in the wall

*Bring out the catheter through a stab wound in the abdominal wall.

Instruments.

Gastro intestinal set

Foley 14 F

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GASTROSTOMY PROCEDURE 4

Gastrostomy

When is gastrostomy required ?

In cases of;

* Obstruction of oesophagus e.g.carcinoma to feed the patient and drain the stomach

* In cases of prolonged ileus or pacreatitis to keep stomach empty

Position of patient.

Supine.

Anaesthesia

General or local

Surgical steps

*Small midline incision

*Left anterior wall of stomach is held between two babcock's forceps midway between greater and lesser curvature

*Two purse string sutures from a selected site for entry.

*The stomach is incised at the selected point.A 14F foley's catheter is inserted through the opening and the two purse string tied around the catheter.

*The catheter is brought out through a stab on the anterior abdominal wall

*The stomach is anchored to the posterior peritoneum and rectus sheath.

Instruments used

*Laprotomy set

*Foley's catheter 14F
*Fine artery forceps 4

 

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PYLOROPLASTY PROCEDURE 3

PYLOROPLASTY

What are the indications of pyloroplasty?

·        In cases to avoid holding up to stomach contents.

·        In patients of peptic ulcer after truncal vagotomy.

·        In patients having cancer of oesophagus after total oesophagectomy to enlarge the passage of the pylorus.

Position of the patient

Suspine.

Anaesthesia given

General.

Surgical steps

·        First the pylorus is located and a longitudinal incision, 3 – 5 cm on stomach side and 2.5cm on duodenal side is given cutting through the pylorus. All bleeding is controlled with ligatures.

·        The longitudinal incision is sutured in a transverse direction using interrupted sutures.

Instruments used

General set, 1

Laparotomy set, 1

Fine artery forceps, 4

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GASTRO JEJUNOSTOMY PROCEDURE 2

When is gastrojejunostomy carried out?

· Gastrojejunostomy is carried out in cases of obstruction of stomach outlet.

· This can result because of cancer or an ulcer of the stomach.

· To establish alternative connection between stomach and small intestine.

· To follow vagotomy.

Position of the patient

Supine.

Anaesthesia given during this procedure

General.

Procedure

· A midline or paramedian incision is made, next an opening is made in transverse mesocolon.

· Stomach antrum is isolated and tissue forceps is applied at lesser and greater curvature of the stomach.

· The jejunum is also held by tissue forceps loop 10 – 20 cm from duodenojejunal junction.

· Next non-crushing occlusion clamp is applied.

- Two-layer anastomosis with 2/0 chromic is now carried out. The outer is continuous (in the seromuscular layer) and the inner continuous to all layers.

- Also anastomosis is brought above the mesocolon tethered.

- Wound is closed in layers.

Instruments

General set, 1

Laparotomy set, 1

Fine artery forceps, 5

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VAGOTOMY PROCEDURES 1

VAGOTOMY

When is vagotomy done?

In cases of peptic ulcer:

· Divison of vagus nerve below diaphragm

· To reduce gastric acid secretion.

Position of the patient

Supine.

Anaesthesia

General.

Steps of surgical procedure

· The incision is given in midline/paramedian.

· Next mobilized left lobe of liver.

· Liver, colon and small intestine packed down and towards right.

· Mobilise lower oesophagus.

· Both nerves identified by palpation.

· Cut between ligatures.

· Specimen sent to histology for confirmation.

Instruments

General set, 1

Laparotomy set, 1

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