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


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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.