Small bowel resection

Small bowel resection is a procedure to remove a diseased segment of small bowel, which can most frequently be indicated due to hernia or volvulus, Crohn disease, malignancy (may necessitate regional lymph node dissection), trauma, obstruction, and vasculopathy. This procedure may be done laparoscopically or open via a vertical or transverse incision. Depending on patient stability and the indication for the resection, the following variants on anastomosis may be performed: open or closed end-to-end, side-to-side, or stapled, functional end-to-end.

Preoperative management

Patient evaluation

Respiratory: Depending on the indication for small bowel resection, the patient may have respiratory insufficiency (e.g. due to pain, bowel distension, tumor, ascites). This may manifest with a decreased FRC, leading to increased A-a gradient and arterial hypoxemia. Consider ABG or CXR.

Cardiovascular: Patients undergoing elective small bowel resection may have hypovolemia due to bowel preparation, while a patient undergoing emergent small bowel resection is likely in critical condition and may have resulting hypovolemia. Consider ECG, fluid resuscitation prior to induction of anesthesia.

Gastrointestinal: Patients may have electrolyte abnormalities due to diarrhea, vomiting, and NPO status. Patients may be malnourished. Consider electrolytes, coags.

Renal: Patients may have acute kidney injury or renal failure, particularly in setting of hypovolemia. Consider BUN, Cr, electrolytes.

Laboratory: CBC with differential, active T&S, consider T&C.

Premedication: Consider midazolam 1-2 mg iv and Na citrate¹ (30 ml po 10 minutes before surgery), acetaminophen 1000 mg po², prophylactic heparin dosing, cefoxitin 2 g iv preop.

Regional and neuraxial techniques: Patients may benefit from transversus abdominis plane block or thoracic epidural block with surgeon agreement if procedure is done open³.

Intraoperative management

Monitoring and access: standard monitors, urine output, 2 PIV (16-18 ga), consider arterial line.

Induction and airway management: GETA with or without epidural for postop analgesia. Patient may benefit from rapid-sequence intravenous induction given risk for aspiration in setting of intra-abdominal pathology⁴.

Positioning: supine, arms typically tucked if laparoscopic, out if open, eyes taped, and pressure points padded.

Maintenance: gastric tube for gastric decompression prior to insufflation, if laparoscopic. Maintain neuromuscular blockade with ToF assessment. If the patient has an epidural catheter, this can be used as a continuous infusion or with bolus dosing and serve as an anesthetic and increase bowel contraction, muscle relaxation to aid the surgeons. Consider a loading dose with an opioid 1 hour prior to termination of surgery if the catheter will remain for postoperative pain control. Fluids and vasoactive medication may be necessary for BP support in the patient receiving epidural anesthetics. Patients may have vagal response to insufflation (peritoneal stretch)⁵.

Emergence: Avoid coughing with emergence if open procedure to avoid increased intra-abdominal pressure against incision (consider deep extubation). Prevention of post-operative nausea and vomiting with ondansetron and dexamethasone.

Postoperative management

Pain management: consider epidural analgesia vs. TAP block⁶, or alternatively consider opioid (PCA vs fixed dose) with NSAID, acetaminophen, gabapentin for multimodal analgesia depending if laparoscopic or open procedure⁷. Consider chewing gum for ileus prevention⁸.

Complications: PONV, Ileus, DVT, atelectasis, hypoxemia, hemorrhage, dehiscence if significant coughing on extubation

Resources:

¹Lim SK, Elegbe EO. The use of single dose of sodium citrate as a prophylaxis against acid aspiration syndrome in obstetric patients undergoing caesarean section. Med J Malaysia. 1991 Dec;46(4):349-55.

²Cain KE, Iniesta MD, Fellman BM, Suki TS, Siverand A, Corzo C, Lasala JD, Cata JP, Mena GE, Meyer LA, Ramirez PT. Effect of preoperative intravenous vs oral acetaminophen on postoperative opioid consumption in an enhanced recovery after surgery (ERAS) program in patients undergoing open gynecologic oncology surgery. Gynecol Oncol. 2021 Feb;160(2):464-468.

³Borzellino G, Francis NK, Chapuis O, Krastinova E, Dyevre V, Genna M. Role of Epidural Analgesia within an ERAS Program after Laparoscopic Colorectal Surgery: A Review and Meta-Analysis of Randomised Controlled Studies. Surg Res Pract. 2016;Aug: 7543684.

⁴Dunn D. Cricoid Pressure: Contradictory Evidence Regarding a Standard Practice. AORN J. 2022 May;115(5):423-436.

⁵Gutt CN, Oniu T, Mehrabi A, Schemmer P, Kashfi A, Kraus T, Büchler MW. Circulatory and respiratory complications of carbon dioxide insufflation. Dig Surg. 2004;21(2):95-105.

⁶Torgeson M, Kileny J, Pfeifer C, Narkiewicz L, Obi S. Conventional Epidural vs Transversus Abdominis Plane Block with Liposomal Bupivacaine: A Randomized Trial in Colorectal Surgery. J Am Coll Surg. 2018 Jul;227(1):78-83.

⁷Joshi GP, Bonnet F, Kehlet H; PROSPECT collaboration. Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis. 2013 Feb;15(2):146-55.

⁸Li S, Liu Y, Peng Q, Xie L, Wang J, Qin X. Chewing gum reduces postoperative ileus following abdominal surgery: a meta-analysis of 17 randomized controlled trials. J Gastroenterol Hepatol. 2013 Jul;28(7):1122-32.