General anesthesia is used. The patient may be positioned supine or in the modified Lloyd-Davies position, with a urinary catheter in the bladder.

The objective of the procedure is to divide the adhesion(s) responsible for the surgical indication, nearly always small bowel obstruction. Adhesions can vary from a single band, which is usually divided with either the scalpel, diathermy, or dissecting scissors, to complex adhesions encasing and joining the bowel and/or other organs.

Previous surgery, inflammation, abscess, irradiation damage, or the presence of mesh often adds complexity. Irrigation and blunt dissection can significantly aid the development of planes between the small bowel serosa and other tissues.

Irrigation using a drawing-up cannula connected to a standard I/V set or the “irrigating” scalpel aids in dissection by creating a plane of “edema” around the small bowel and washing away any blood or fluid, making the dissection of adhesions easier. Alternatively injection of saline with a hypodermic syringe has similar benefits. Judicious use of the diathermy at a low setting has a similar effect with heat and fumes generated, opening up the plane for dissection

Peritoneal lavage with warm saline is performed to remove debris and contamination. Serosal tears may be recognized by the “stripe” sign indicating the exposure of the underlying smooth muscle bands, which should be repaired transversely with continuous monofilament absorbable suture before full-thickness perforation occurs. Excision any necrotic or frayed tissue is usually prudent.

There are few congenital abnormalities that change the anatomy of the small bowel except Merkel’s diverticulum, malrotation, and the presence of Ladd’s bands in the right upper quadrant. The major variation that is relevant in this operation is the site and extent of the adhesions.

See Table 6.2. This operation can be one of the most demanding in general surgery, particularly when dealing with multiple adhesions, especially those associated with irradiation, abscesses, or mesh. The ultimate objective is to divide all adhesions without sustaining injury to the small bowel or other organs. Breaches of the serosa are not uncommon, and full thickness (enterotomy) may occur in up to 40 % of cases with dense adhesions. Serosal tears may be repaired with interrupted monofilament absorbable material. Resection of a damaged small bowel segment may be necessary. The operation notes should include a diagram of the sites of enterotomies and resection lengths measured from the duodenal-jejunal (DJ) flexure. The consequences of enterotomy are significant and include wound infection, wound dehiscence, small bowel obstruction, intra-abdominal abscess, intra-abdominal leak, perforation of small bowel content with generalized peritonitis, and enterocutaneous fistula.

The main complications arise from perforation, either concealed or revealed, occurring during division of adhesions. Infection, including abscess formation, wound infection, and peritonitis, may occur and be serious sometimes leading to multisystem organ failure. Bleeding is rarely serious, but oozing can be problematic and may cause mesenteric hematoma(s) that can become infected. Wound dehiscence and enterocutaneous fistula formation are serious but less common problems. Small bowel obstruction can recur and may be a repetitive, monotonous problem, requiring much hospitalization and surgery.

General anesthesia is used. Patient may be positioned, with a urinary catheter, supine or in the modified Lloyd-Davies position to provide better access for the scrub nurse or for the surgeon in accessing the left upper quadrant of the stomach. If irrigation is being used to aid in the dissection, then a plastic incisive drape combined with adhesive irrigation bags is useful.

If this is “redo” or reentry surgery, access is best achieved by also extending the incision above/below the existing scar into the “virgin” abdominal wall. The old scar should be excised. Entry to the abdominal cavity should be by careful dissection with combination of sharp dissection and irrigation or diathermy.

The objective of the operation is to perform a resection of the small bowel with end-to-end anastomosis. A good arterial blood supply in both bowel ends is essential before attempting an anastomosis. Single- or double-layer continuous techniques using monofilament absorbable suture material are usually used. Stapling techniques have become popular using a combination of the GIA stapler and linear cutter performing a functional end-to-end (or end-side or side-side) anastomosis.

The most common indications are for multiple adhesions and for ischemic segments from band adhesions. The position(s) of small bowel anastomosis from the DJ flexure and/or ileocecal valve should be measured with a sterile ruler and clearly documented in the operation notes with a diagram.

Contraindications to anastomosis such as intra-abdominal sepsis, significant medical comorbidities, or risk factors reducing wound healing make an ileostomy and mucous fistula preferable, often through the same stomal aperture. Serosal tears may be recognized by the “stripe” sign indicating the exposure of the underlying smooth muscle bands, which should be repaired transversely with continuous monofilament absorbable suture before full-thickness perforation occurs. Excision of any necrotic or frayed tissue is usually prudent.

There are a few anatomical points that affect the small bowel except for Meckel’s diverticulum, malrotation of the cecum, and Ladd’s bands. Situs abdominus inversus is very rare.

See Table 6.3. The complications of this operation often depend on the initial pathology for which the procedure was performed. The most serious complication being anastomotic leakage, the risk of which is increased by distal obstruction, often caused by distal adhesions, hence the need to dissect all adhesions from the DJ flexure to the ileocecal valve. The consequence of an anastomotic leakage is contamination of the peritoneal cavity, leading to generalized peritonitis or intra-abdominal abscess formation, typically in the paracolic gutters, pelvis, or the subphrenic spaces. Anastomotic leakages are reduced, by ensuring good blood supply to the bowel ends, no tension, and no factors contraindicating an anastomosis. Wound infection, small bowel obstruction, and enterocutaneous fistula are significant but fortunately uncommon complications.

The main complications arise from perforation, either concealed or revealed, occurring during division of adhesions/bowel resection. Anastomotic leakage is a serious complication and may lead to generalized or localized sepsis. Infection, including abscess formation, wound infection, and peritonitis, may occur and be serious sometimes leading to multisystem organ failure and is the main cause of death when it occurs. Bleeding is rarely serious, but oozing can be problematic and may cause mesenteric hematoma(s) that can become infected. Wound dehiscence and enterocutaneous fistula formation are serious but less common problems. Small bowel obstruction can recur and may be a repetitive, monotonous problem, requiring much hospitalization and surgery.

General anesthesia is used. Preoperative counselling and siting with a stomal therapist is desirable. Positioning may be supine or in the modified Lloyd-Davies position with a urinary catheter to provide better access for the scrub nurse or for the surgeon in accessing the left upper abdominal quadrant.

If irrigation is being used to aid in the dissection, then a plastic incisive drape combined with adhesive irrigation bags is useful.

If this is “redo” or “reentry” surgery, access is best achieved by also extending the incision above/below the existing scar into the “virgin” abdominal wall. The old scar should be excised. Entry to the abdominal cavity should be by careful dissection with combination of sharp dissection and irrigation or diathermy.

This procedure is often performed where it is unsafe to perform a small bowel anastomosis because of the presence of intra-abdominal sepsis, past irradiation, or mesh or in a patient who has medical comorbidities or other risk factors that reduce wound healing capacity, e.g., diabetes, renal failure, or malnutrition.

The aim therefore is to create a stoma using the proximal end of the small bowel that has been resected and create a mucous fistula of the distal end. This procedure is often performed in the emergency setting. Ideally the stoma should be properly sited preoperatively. In the emergency setting, this is in the horizontal plane 3–4 cm to the right of the umbilicus. The aperture in the skin and the abdominal wall should be adequate so that the proximal small bowel and the distal small bowel can easily be passed through the aperture with their associated mesentery (2–3 finger widths). An end ileostomy with a “spout” of at least 2 cm fashioned using a Brooke technique aids skin protection and bag entry. The distal bowel mucous fistula can be brought out adjacent to the end ileostomy through the same aperture. Stapling the distal end after confirming that it is distal using a linear stapler and suturing the end of the staple line with a monofilament nonabsorbable suture material to the rectus sheath removes the mucous fistula and allows the whole aperture for the end ileostomy. The site of the stoma and distal bowel length should be measured by sterile ruler and clearly documented using a diagram in the operation notes. The abdominal wall and skin should be closed before fashioning/maturing the stoma to reduce contamination.

There are a few anatomical points that affect the small bowel except for Meckel’s diverticulum, malrotation of the cecum, and Ladd’s bands. A shortened mesentery or severe obesity may make obtaining sufficient SB length difficult for stoma formation. Situs abdominus inversus is very rare.

See Table 6.4. Major complications of this operation often relate to complications of the ileostomy. Most serious in the initial postoperative period is ischemia of the stoma, avoided by ensuring good blood supply to the bowel ends, no tension, an adequate aperture, and no factors contraindicating ileostomy. Ischemia and retraction may lead to intraperitoneal leakage and generalized or localized peritonitis and sepsis. The initial pathology for which the procedure was performed and comorbidities often determine complications experienced. Fistula formation occurring in the small bowel proximal to the stoma may create a peristomal abscess, and leakage of small bowel contents into the subcutaneous tissue can be severely problematic.

Longer-term stoma complications include retraction, prolapse, peristomal hernia, and stenosis. Almost all stomas formed eventually develop some form of complication. Persistent proximal or even distal obstruction can be problematic in ensuring stomal function and distal SB drainage, respectively. Stomal skin problems and bag adherence are common issues that are troublesome.

Wound infection, small bowel obstruction, and enterocutaneous fistula are significant but fortunately uncommon complications. Later reversal of the ileostomy may be considered and is usually straightforward, but can be challenging in some situations.

The main complications arise from perforation, either concealed or revealed, occurring during division of adhesions/bowel resection. Stomal ischemia, retraction, and leakage are serious complications and may lead to generalized or localized sepsis. Infection, including abscess formation, wound infection, and peritonitis, may occur and be serious sometimes leading to multisystem organ failure and is the main cause of death when it occurs. Bleeding is rarely serious, but oozing can be problematic and may cause mesenteric hematoma(s) that can become infected. Wound dehiscence and enterocutaneous fistula formation are serious but less common problems. Small bowel obstruction can recur and may be a repetitive, monotonous problem, requiring much hospitalization and surgery. Later ileostomy reversal is associated with risk of obstruction, leakage, and sepsis.

General anesthesia is used. Positioning is in the supine or in the modified Lloyd-Davies position with a urinary catheter to provide better access for the scrub nurse or for the surgeon in accessing the left upper abdominal quadrant. If irrigation is being used to aid in the dissection, then a plastic incisive drape combined with adhesive irrigation bags is useful. Often this is “redo” surgery and access is best achieved by also extending the incision above/below the existing scar into the “virgin” abdominal wall. The old scar should be excised. Entry to the abdominal cavity should be by careful dissection with combination of sharp dissection and irrigation or diathermy. The objective of this operation is to perform a bypass usually for a malignant or inflammatory obstruction that is not resectable. For this reason, the proximal bowel is typically dilated and the distal small bowel collapsed. The anastomosis is almost always side to side using longitudinal enterotomies in the proximal and distal bowel, using a single-layer continuous monofilament absorbable suture material alone or with a GIA stapler. It is usual to perform some form of decompression of the proximal bowel to relieve pressure and allow better approximation – the authors favor either an intercostal thoracic catheter attached to suction with a side hole cut in the catheter to allow decompression with lower pressure suction or a large-bore (16G) needle attached to a 5 ml syringe with plunger removed to take the end of the suction tubing. The tube/needle is moved around to extract gas and fluid and the insertion hole(s) closed with 3/0 monofilament absorbable sutures. Serosal tears may be recognized by the “stripe” sign indicating the exposure of the underlying smooth muscle bands, which should be repaired transversely with continuous monofilament absorbable suture before full-thickness perforation occurs. Excision any necrotic or frayed tissue is usually prudent.

There are a few anatomical points that affect the small bowel except for Meckel’s diverticulum, malrotation of the cecum, and Ladd’s bands. Situs abdominus inversus is very rare. Previous surgery and the underlying pathology, causing acquired anatomical distortion or modification, largely determine the technical difficulties encountered.