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L. Findji1
1Fitzpatrick Referrals, Oncology and Soft Tissue surgery, Guildford, United Kingdom
Tips and Tricks for Small intestinal surgery
Enterotomies and enterectomies are most often simple procedures, which can however have devastating consequences if not performed properly, as septic peritonitis invariably results from intestinal wound dehiscence. This text assumes that the reader has a basic knowledge of these techniques, which will not be reviewed. It only focuses on a few points which should help maximise ef ciency and improve outcomes in small intestinal surgery.
Be atraumatic
The pursuit of the unreachable goal of atraumatic surgery is common to all surgical procedures. Respecting
tissues and leaving them as healthy as possible is the main key to success. Brie y, it consists of handling tissues delicately (which includes keeping them moist), preserving their vascularisation and limiting their
bacterial contamination. Respecting the vascularisation is paramount in the success of the procedure. Any excessive exteriorisation of the intestines impairs its blood  ow and should be avoided. Similarly, care must be taken not to compress the jejunal arteries and veins during the procedure.
Using atraumatic means of temporarily occluding the intestinal lumen is also critical, whether it be non- traumatic Doyen forceps or the assistant surgeon’s  ngers.
Isolate the surgical  eld
Entero- and enterectomies involve opening a contaminated hollow viscus. The surgical  eld must therefore be isolated from the rest of the abdominal cavity as much as possible to limit bacterial contamination. However, unless it is massive and unaddressed, bacterial contamination is not a limiting factor in the success of intestinal surgery.
When the procedure involves a portion of intestine that can easily be exteriorised, which is the case of the greatest part of the jejunum and ileum, an ef cient way to isolate it is to use a fenestrated impervious paper drape through which the intestinal loops of interest are passed. Fenestrated, moist laparotomy swabs can be used on both sides of the drape to help keep tissues moist. Once
the septic step of the procedure is over, the exposed intestines and intestinal wound are copiously rinsed over this additional drape, which is then removed with the moist laparotomy swabs. Instruments and gloves are either rinsed or changed, depending on the degree of contamination, and surgery can proceed routinely.
Enterotomy tips
Biopsies of the small intestine should be small, so that no reduction of the intestinal lumen results from it,
but include all layers of the intestinal wall. To achieve these goals, a useful tip is to pass a suture through the intestinal wall on its antimesenteric border. Gentle vertical traction is exerted on the suture and a small wedge incision is made longitudinally on each side of it to resect as small a portion of the wall as possible with a surgical blade. If the biopsy is kept small, there is no need to close the wound transversally to avoid stenosis of the intestinal lumen. As for enterotomy and enterectomy, a 1-layer, full-thickness suture pattern is used for closure.
When removing a linear intestinal foreign-body, the number of enterotomies required can be reduced to 1 or 2 by using a urinary catheter for dogs. An enterotomy is made orally (often on the descending duodenum), which allows recovering the oral portion of the foreign body (typically stuck around the base of the tongue in cats and in the pylorus in dogs). The foreign body is then attached to the extremity of the sterile urinary catheter, which is then fed into the intestinal lumen. It is then moved aborally by taxis, until it reaches the ileum. In many cases, it can be moved further aborally and be recovered through the anus by a non-scrubbed assistant. If not, a second enterotomy is made on the ileum to remove the catheter and the entire foreign body from the intestinal lumen.
One-layer, full-thickness appositional sutures
Entero- and enterectomy wounds must be sutured in one- layer, appositional sutures to prevent stenosis. Interrupted or continuous sutures can be used. It is critical to include the submucosa in all sutures, which most often means that full-thickness sutures must be used.
Mucosal eversion management
When the intestinal wall is incised, the mucosa and submucosa tend to everse, as the  bres of the longitudinal smooth muscle retract. Whereas this is not a factor limiting success, suturing the intestines with everted mucosa leads to second-intention healing of the wound by lack of apposition of layers. Two techniques can be used to suture intestines with everted mucosa: the everted mucosa can be trimmed or modi ed Gambee sutures can be used to push the mucosa and submucosa into the lumen as sutures are placed.
An Urban Experience

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