Repair of wall injuries
When small bowel wounds are detected, surgical tactics depend on the size of the defect. The operation is usually performed via median laparotomy.
- Puncture (stab) wounds: closed with a single purse-string seromuscular suture. As the thread is tightened, the edges of the defect are gently inverted into the lumen using anatomical forceps.
- Incised wounds (several centimeters long): require a classic double-layer suture. First, the inner layer is formed using a catgut thread through all layers of the wall, applying an inverting Schmieden suture. Then, the outer layer is applied, consisting of interrupted seromuscular sutures (silk is used).
The main rule when closing longitudinal defects is that they must be converted into a transverse direction. This is a crucial measure for preventing postoperative stricture (stenosis) of the intestinal tube. The intervention is completed by thoroughly drying the abdominal cavity, after which the abdominal wall wound is closed tightly.
Creation of intestinal fistulas (enterostomy)
The creation of an artificial fistula pursues two main goals: providing nutrition for the patient or diverting intestinal contents.
- Jejunostomy (Witzel procedure): applied to the jejunum 40–50 cm away from the flexura duodenojejunalis. Indicated when gastrostomy is impossible (e.g., due to widespread cancer or chemical burn of the stomach). During the intervention, a Braun enteroenterostomy is formed between the afferent and efferent loops. The feeding tube is placed onto the efferent loop, embedded into the serosal channel with interrupted silk stitches, and its tip is inserted through a small incision into the lumen distal to the anastomosis. The opening is sealed with a purse-string and interrupted sutures, the tube is fixed with catgut to prevent slipping, and brought out through a separate stab incision. The intestine must be sutured to the parietal peritoneum.
- Ileostomy: exteriorization of an ileal loop for decompression. Through a right-sided incision, the intestine is brought out, and the parietal peritoneum is fixed to the edges of the skin wound. The intestinal wall is opened, and its edges are sutured to the skin to form a spout (lip-like) fistula. Subsequently, such a fistula is closed during a secondary operation.
Resection with anastomosis
Removal of an intestinal segment is indicated for tumors, multiple injuries, or necrosis (due to strangulated hernia, acute obstruction, or mesenteric artery thrombosis). The operation is performed under endotracheal anesthesia. After mobilization of the mesentery (either parallel to the intestine or wedge-shaped), the surgeons form the anastomosis.
End-to-end anastomosis To preserve adequate blood supply to the antimesenteric border and widen the lumen, rigid clamps are applied obliquely at a 45° angle. Soft clamps are placed 1.0–1.5 cm lateral to the resection line. The intestine is transected parallel to the rigid clamps, after which the ends are brought together and sutured:
- Posterior wall: outer layer (interrupted seromuscular sutures focusing on the mesenteric border), then soft clamps are removed, and the inner layer is applied (continuous locking catgut suture).
- Anterior wall: inner layer (Schmieden suture with the same thread), then outer layer (interrupted silk sutures).
The mesenteric defect is closed with separate silk stitches.
Side-to-side anastomosis In this case, rigid clamps are applied transversely. The ends are closed tightly according to the Doyen method (catgut ligation, purse-string suture 1.5 cm from the ligation, invagination of the stump, seromuscular sutures). The stumps are placed against each other isoperistaltically, avoiding twisting.
The anastomosis is formed: the first row of sutures (posterior wall) is applied over a length of 8 cm with 0.5 cm intervals. The lumen is opened 0.5 cm away from the suture line and 0.75 cm from the free edge (the incision length stops 1 cm short of the suture ends). The inner row of sutures is applied with catgut (posterior lips with a continuous suture, anterior lips with a Schmieden suture), and the outer row with silk. The blind ends are meticulously fixed to the intestinal wall to prevent invagination.
Important nuance: before placing the final second layer of seromuscular sutures, surgical instruments must be changed or removed, and hands treated with antiseptic.
Briefly: answers to topical questions
Why is a Braun enteroenterostomy formed during a Witzel jejunostomy?
A Braun enteroenterostomy is formed to prevent the development of a "vicious circle". In a Witzel jejunostomy, it is placed between the afferent and efferent loops of the jejunum.
How is the needle passed through the wall layers when applying a Schmieden suture?
When applying a Schmieden suture, the needle with the thread is passed through all layers of the intestinal wall strictly in one direction—from inside to outside. The puncture is made sequentially from the mucosa to the serosa on one edge, and then from the mucosa to the serosa on the other edge. This continuous inverting whipstitch ensures reliable approximation of the edges: upon tightening the thread, the walls are inverted into the lumen, closely approximating their serosal surfaces.
What methods of mesenteric vessel ligation exist during its mobilization?
During intestinal mobilization, the mesentery is divided in two ways:
- Parallel to the intestine — at the level of straight arteries.
- Wedge-shaped — closer to the root of the mesentery, with prior vessel ligation.
The wedge-shaped method is used for extensive resections or tumors.
In what cases is a side-to-side anastomosis preferred over an end-to-end anastomosis?
A side-to-side anastomosis is used when it is necessary to avoid stricture of the anastomosis: its width is not limited by the diameter of the intestines and is freely adjustable. In the surgical treatment of small bowel Crohn's disease, a stapled side-to-side anastomosis is preferred because this technique reduces the probability of anastomotic leakage and subsequent stricture development. In such an anastomosis, the stumps are closed tightly, the loops are positioned isoperistaltically and connected by their lateral surfaces.
To remember the layers of the classic double-layer suture: "Inside is everything (all layers are sutured) and absorbs (catgut); outside is only muscle and serosa (seromuscular) and holds strong (silk)."
Class and exam questions
Why is a longitudinal intestinal wound closed in the transverse direction?
This is necessary for strict prevention of stenosis. If a wound is closed longitudinally, the lumen of the intestinal tube at this site will narrow significantly, which can lead to obstruction.
Why is the intestine transected at a 45-degree angle during an end-to-end resection?
An oblique cut allows for the removal of more tissue at the antimesenteric border, where blood supply is objectively poorer. In addition, it mechanically increases the diameter of the formed anastomosis.
What is the essence of stump management using the Doyen method?
The intestine is ligated with a catgut ligature, transected, and then the resulting stump is invaginated into the lumen using a purse-string suture. Additional seromuscular sutures are invariably placed over it.
Why are jejunostomy and ileostomy performed?
Jejunostomy (a fistula on the jejunum) is needed for artificial enteral nutrition of the patient, while ileostomy (on the ileum) is for the diversion of intestinal contents outward.
What else to study on this topic
- Technique of forming a Braun enteroenterostomy
- Features of mesenteric mobilization (wedge-shaped and parallel)
- Technique of performing the inverting Schmieden suture
- Topographic anatomy of the duodenojejunal flexure
- Steps for creating a spout ileostomy
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