Small Bowel Resection & Anastomosis
What the Examiner Expects
Resection of a segment of small intestine with restoration of intestinal continuity via anastomosis. The examiner expects you to determine the indication, assess bowel viability (color, peristalsis, palpable mesenteric pulsation, Doppler if questionable, ICG fluorescence angiography), resect to healthy margins, and create a tension-free, well-vascularized anastomosis. A side-to-side functional end-to-end stapled anastomosis is most commonly performed using a GIA stapler to create the common channel and a TA stapler to close the common enterotomy. Hand-sewn anastomosis in two layers (running inner, interrupted outer Lembert) is an acceptable alternative.
Key Examiner Focus Points
- Indications: ischemia, tumor, Crohn's stricture, trauma, incarcerated hernia with necrosis
- Assess viability: color, peristalsis, mesenteric pulsation, Doppler, ICG fluorescence
- Stapled vs hand-sewn anastomosis — both acceptable on boards
- Preserve as much bowel length as possible (short bowel syndrome if < 200 cm)
- Side-to-side (functional end-to-end) stapled anastomosis is most common
Common Curveballs
After resection for mesenteric ischemia, the remaining bowel viability is questionable
Perform a second-look laparotomy in 24–48 hours. Do NOT create an anastomosis on questionable bowel. Leave the bowel in discontinuity, use damage control principles, and reassess at planned re-exploration.
Patient has had multiple prior small bowel resections for Crohn's and has only 150 cm of small bowel remaining
Preserve bowel length — consider strictureplasty instead of resection for short fibrotic strictures. Short bowel syndrome occurs with < 200 cm of remaining small bowel (< 100 cm without a colon). If short bowel syndrome develops, manage with TPN, trophic enteral feeds, GLP-2 analogs (teduglutide).
Anastomotic leak on POD 5 with peritonitis
Return to OR. If the patient is stable and contamination is limited, consider re-resection and primary anastomosis. If the patient is septic or hemodynamically unstable, resect the anastomosis and bring up both ends as stomas (damage control). Do not attempt a redo anastomosis in a septic abdomen.
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