Surgery of the Small Intestine - kisallatsebeszet.hu of the Small Intestine Dr. T. Németh, DVM, PhD...

Surgery of the Small Surgery of the Small IntestineIntestine

Surgery of the Small Surgery of the Small IntestineIntestine

Dr. T. Németh, DVM, PhDDr. T. Németh, DVM, PhDAssociate Professor of SurgeryAssociate Professor of SurgeryDr. T. Németh, DVM, PhDDr. T. Németh, DVM, PhDAssociate Professor of SurgeryAssociate Professor of Surgery

SurgerySurgery of of thethe SmallSmall IntestineIntestineSurgicalSurgical anatomyanatomy


Surgery of the Small IntestineSurgery of the Small IntestineSurgical anatomy 1.Surgical anatomy 1.


�� Macroscopic anatomyMacroscopic anatomy–– duodenum (desc., transv., asc.)duodenum (desc., transv., asc.)

–– jejunumjejunum

–– ileumileum

�� HistologyHistology–– mucosa (enterocyták, Lieberkühn crypts, mucosa (enterocyták, Lieberkühn crypts,

microvilli)microvilli)

–– submucosa (Meissner plexus)submucosa (Meissner plexus)

–– muscularis (ext.muscularis (ext.-- longit.., int. longit.., int. -- circ.)circ.)

–– serosaserosa

�� Macroscopic anatomyMacroscopic anatomy–– duodenum (desc., transv., asc.)duodenum (desc., transv., asc.)

–– jejunumjejunum

–– ileumileum

�� HistologyHistology–– mucosa (enterocyták, Lieberkühn crypts, mucosa (enterocyták, Lieberkühn crypts,

microvilli)microvilli)

–– submucosa (Meissner plexus)submucosa (Meissner plexus)

–– muscularis (ext.muscularis (ext.-- longit.., int. longit.., int. -- circ.)circ.)

–– serosaserosa









�� Blood supplyBlood supply–– cran., caud. pancreaticoduod. (celiac)cran., caud. pancreaticoduod. (celiac)

–– jejunale (cran. mes.)jejunale (cran. mes.)

–– ilei, ileocolica (cran. mes.)ilei, ileocolica (cran. mes.)

–– portal drainageportal drainage

�� Lymphoid drainageLymphoid drainage–– cran. mesent. lnn. cran. mesent. lnn.

�� InnervationInnervation–– vagus n. (parasymp.)vagus n. (parasymp.)

–– cran. mesent. ggl. (symp.)cran. mesent. ggl. (symp.)

�� Blood supplyBlood supply–– cran., caud. pancreaticoduod. (celiac)cran., caud. pancreaticoduod. (celiac)

–– jejunale (cran. mes.)jejunale (cran. mes.)

–– ilei, ileocolica (cran. mes.)ilei, ileocolica (cran. mes.)

–– portal drainageportal drainage

�� Lymphoid drainageLymphoid drainage–– cran. mesent. lnn. cran. mesent. lnn.

�� InnervationInnervation–– vagus n. (parasymp.)vagus n. (parasymp.)

–– cran. mesent. ggl. (symp.)cran. mesent. ggl. (symp.)

Surgery of the Small IntestineSurgery of the Small IntestinePhysiological reviewPhysiological review 1.1.


�� NutrientNutrient--digestion and digestion and --absorbtionabsorbtion–– lipids, proteins, carbohydrateslipids, proteins, carbohydrates

–– intestinal secretion intestinal secretion

–– pancreatic secretion (neutralizálás, emésztés)pancreatic secretion (neutralizálás, emésztés)

–– bile bile

�� NutrientNutrient--digestion and digestion and --absorbtionabsorbtion–– lipids, proteins, carbohydrateslipids, proteins, carbohydrates

–– intestinal secretion intestinal secretion

–– pancreatic secretion (neutralizálás, emésztés)pancreatic secretion (neutralizálás, emésztés)

–– bile bile



�� MotilityMotility–– triple function triple function

�� mixing (segmental move)mixing (segmental move)

�� contribution of absorbtion (move of macrovilli)contribution of absorbtion (move of macrovilli)

�� intestinal passage (peristaltic move)intestinal passage (peristaltic move)

–– vagal n. vagal n. ------ sympathic n.sympathic n.–– special reflexesspecial reflexes

�� intestinointestinal reflexintestinointestinal reflex

�� ileogastric ileogastric -- gastroileal reflexgastroileal reflex

�� MotilityMotility–– triple function triple function

�� mixing (segmental move)mixing (segmental move)

�� contribution of absorbtion (move of macrovilli)contribution of absorbtion (move of macrovilli)

�� intestinal passage (peristaltic move)intestinal passage (peristaltic move)

–– vagal n. vagal n. ------ sympathic n.sympathic n.–– special reflexesspecial reflexes

�� intestinointestinal reflexintestinointestinal reflex

�� ileogastric ileogastric -- gastroileal reflexgastroileal reflex

Small Intestinal ObstructionSmall Intestinal Obstruction(SIO)(SIO)

Small Intestinal ObstructionSmall Intestinal Obstruction(SIO)(SIO)

General considerationsGeneral considerationsGeneral considerationsGeneral considerations

�� Definition Definition -- permanent blockage of the flow of intestinal contents (chyme) ⇒

�� Small Small intestinal obstructionintestinal obstruction--------LargeLarge intestinal intestinal obstructionobstruction

�� LocalLocal changes changes ⇒ life-threatening general consequences

� ”Acute abdomen"

�� Definition Definition -- permanent blockage of the flow of intestinal contents (chyme) ⇒

�� Small Small intestinal obstructionintestinal obstruction--------LargeLarge intestinal intestinal obstructionobstruction

�� LocalLocal changes changes ⇒ life-threatening general consequences

� ”Acute abdomen"

ClassificationClassificationClassificationClassification�� MechanicMechanic

�� obturationobturation

�� intussusceptionintussusception

�� torsion, volvulustorsion, volvulus

�� adhesionadhesion�� stricturestricture

�� strangulationstrangulation

�� incarcerationincarceration

�� atresia, stenosisatresia, stenosis

�� compressioncompression

�� MechanicMechanic�� obturationobturation








�� FunctionalFunctional–– spasticspastic

�� reflectoryreflectory

�� combined with combined with mechanic mechanic obstructionobstruction

�� CNS diseaseCNS disease

–– paralyticparalytic�� peritoneal irritationperitoneal irritation


�� metabolic disordermetabolic disorder








PathogenesisPathogenesis of SIO of SIO PathogenesisPathogenesis of SIO of SIO PathogenesisPathogenesis of SIOof SIOPathogenesisPathogenesis of SIOof SIO�� Local changesLocal changes

–– Oral sectionOral section� stagnation and sequestration of chyme, abnormal digestion of

intestinal contents,intraluminal gas and fluid accumulation� toxin formation� vomiting → loss of Hydrogen and acids

–– Obstructed sectionObstructed section� spasm of intestine � disruption of intestinal blood supply: congestion, oedema,� necrosis, arrodation,rupture/perforation

–– Aboral sectionAboral section� caudal emptying of chyme� „chicken-bowel"� malabsorption: loss of kalium and carbonate.

�� Local changesLocal changes–– Oral sectionOral section

� stagnation and sequestration of chyme, abnormal digestion of intestinal contents,intraluminal gas and fluid accumulation

� toxin formation� vomiting → loss of Hydrogen and acids

–– Obstructed sectionObstructed section� spasm of intestine � disruption of intestinal blood supply: congestion, oedema,� necrosis, arrodation,rupture/perforation

–– Aboral sectionAboral section� caudal emptying of chyme� „chicken-bowel"� malabsorption: loss of kalium and carbonate.

PathogenesisPathogenesis of SIOof SIOPathogenesisPathogenesis of SIOof SIO

� General consequences:–– MetabolicMetabolic changeschanges

�� acidosisacidosis v. v. alkalosisalkalosis

�� K, Na, HCO3 K, Na, HCO3 ⇓⇓..

–– cardiomyopathycardiomyopathy ((toxinstoxins, , hypoxiahypoxia))

–– EndotoxemiaEndotoxemia

–– HypovolemiaHypovolemia

�� SHOCK !!!SHOCK !!!

� General consequences:–– MetabolicMetabolic changeschanges

�� acidosisacidosis v. v. alkalosisalkalosis

�� K, Na, HCO3 K, Na, HCO3 ⇓⇓..

–– cardiomyopathycardiomyopathy ((toxinstoxins, , hypoxiahypoxia))

–– EndotoxemiaEndotoxemia

–– HypovolemiaHypovolemia

�� SHOCK !!!SHOCK !!!

General symptoms of SIO 1.General symptoms of SIO 1.General symptoms of SIO 1.General symptoms of SIO 1.

��Abdominal painAbdominal pain

��VomitingVomiting

��Lack of faeces and flatusLack of faeces and flatus

��MeteorismMeteorism

��Abdominal painAbdominal pain

��VomitingVomiting

��Lack of faeces and flatusLack of faeces and flatus

��MeteorismMeteorism


��Abdominal pain Abdominal pain ––„défense musculaire”„défense musculaire”

–– intestinal spasmintestinal spasm

––peritonitis peritonitis

��Abdominal pain Abdominal pain ––„défense musculaire”„défense musculaire”

–– intestinal spasmintestinal spasm

––peritonitis peritonitis


��Vomiting Vomiting – characteristic of the site of obstruction:

� greyish, foamy → pyloric obstruction

� yellowish-greenish, bilious → upper duodenal obstruction

� fecal vomiting/copremesis → lower intestinal obstruction

��Vomiting Vomiting – characteristic of the site of obstruction:

� greyish, foamy → pyloric obstruction

� yellowish-greenish, bilious → upper duodenal obstruction

� fecal vomiting/copremesis → lower intestinal obstruction


�� Lack of faeces and flatusLack of faeces and flatus– exceptions:

� ∗bloody faeces (intussusception)

� ∗irregular defecation (partial obstruction)

�� Lack of faeces and flatusLack of faeces and flatus– exceptions:

� ∗bloody faeces (intussusception)

� ∗irregular defecation (partial obstruction)


��MeteorismMeteorism– gas and fluid-filled distended small

intestinal sections

– physically and radiologically well defined

��MeteorismMeteorism– gas and fluid-filled distended small

intestinal sections

– physically and radiologically well defined

Diagnostics of SIO 1.Diagnostics of SIO 1.Diagnostics of SIO 1.Diagnostics of SIO 1.

�� HistoryHistory–– appetite?, defecation?, vomiting?appetite?, defecation?, vomiting?

–– Possibility of foreign body (?)Possibility of foreign body (?)

–– former operations (!)former operations (!)

�� HistoryHistory–– appetite?, defecation?, vomiting?appetite?, defecation?, vomiting?

–– Possibility of foreign body (?)Possibility of foreign body (?)

–– former operations (!)former operations (!)


�� General examinationGeneral examination–– gen. clinical stategen. clinical state

–– circulatory and respiratory statecirculatory and respiratory state

�� General examinationGeneral examination–– gen. clinical stategen. clinical state

–– circulatory and respiratory statecirculatory and respiratory state


�� Detailed examination Detailed examination (abdomen)(abdomen)–– inspectioninspection

–– palpation (!!!)palpation (!!!)

–– auscultationauscultation

–– percussionpercussion

�� Detailed examination Detailed examination (abdomen)(abdomen)–– inspectioninspection

–– palpation (!!!)palpation (!!!)

–– auscultationauscultation

–– percussionpercussion


�� Supplementary examination Supplementary examination –– X ray (plain, contrast)X ray (plain, contrast)

–– USUS

–– abdominocentesisabdominocentesis

–– laboratory (blood profile, PCV, TPP)laboratory (blood profile, PCV, TPP)

–– orogastric tubationorogastric tubation

–– exploratory laparotomyexploratory laparotomy

�� Supplementary examination Supplementary examination –– X ray (plain, contrast)X ray (plain, contrast)

–– USUS

–– abdominocentesisabdominocentesis

–– laboratory (blood profile, PCV, TPP)laboratory (blood profile, PCV, TPP)

–– orogastric tubationorogastric tubation

–– exploratory laparotomyexploratory laparotomy

ClassificationClassificationClassificationClassification�� MechanicMechanic

�� obturationobturation








�� MechanicMechanic�� obturationobturation






















Types of SIO 1.Types of SIO 1.Types of SIO 1.Types of SIO 1.

�� ObturationObturation�� ObturationObturation

Types of SIO 1.Types of SIO 1.Types of SIO 1.Types of SIO 1.�� ObturationObturation

–– partialpartial oror completecomplete

–– foreignforeign body body inin youngyoung, , playfulplayful dogsdogs and and catscats

–– IntestinalIntestinal tumourstumours inin olderolder patientspatients: : adenocarcinomaadenocarcinoma, , leiomyomaleiomyoma//sarcomasarcoma (dog), (dog), LSA (LSA (catcat))

–– gengen. SIO . SIO symptomssymptoms–– palpablepalpable obstructionobstructionsitesite

–– X X rayray�� plainplain ((directdirect -- indirectindirect signssigns ) )

�� pospos. . contrastcontrast studystudy

–– laparotomylaparotomy((enterotomyenterotomy, , resectionresection, ,

�� ObturationObturation–– partialpartial oror completecomplete







ObturationObturationPlainPlain radiographyradiography




GrahamGraham JP, Lord PF, Harrison JM: Quantitative estimation of intestinal dilationJP, Lord PF, Harrison JM: Quantitative estimation of intestinal dilationas a predictor of obstruction in the dog. J as a predictor of obstruction in the dog. J SmSm AnimAnim PractPract 39(11):52139(11):521––524, 1998. 524, 1998.

HHL5L5

∅∅ ObstructionObstruction: 1.6 > D: 1.6 > DSISI/H/HL5L5

≅≅ ObstructionObstruction: 1.6: 1.6<< DDSISI/H/HL5L5<<2.02.0��ObstructionObstruction: 2.0 : 2.0 << DDSISI/H/HL5L5

DDSISI

ObturationObturationPlain radiographyPlain radiography




ObturationObturationPositive contrast radiographyPositive contrast radiography




Types of SIO 1.Types of SIO 1.Types of SIO 1.Types of SIO 1.�� ObturationObturation

–– partialpartial oror completecomplete







�� ObturationObturation–– partialpartial oror completecomplete







ObturationObturationIntraoperative pictureIntraoperative picture

ObturationObturationIntraoperative pictureIntraoperative picture

ObturationObturationIleumIleum adenocarcinomaadenocarcinoma (dog)(dog)

ObturationObturationIleumIleum adenocarcinomaadenocarcinoma (dog)(dog)

ObturationObturationJejunumJejunum LSA (LSA (catcat))

ObturationObturationJejunumJejunum LSA (LSA (catcat))

�� IntussusceptionIntussusception�� IntussusceptionIntussusception



�� IntussusceptionIntussusception–– primary (unequal peristaltic moves, enteritis) primary (unequal peristaltic moves, enteritis) ------

puppies and kittenspuppies and kittens–– secondary (combined with other type of SIO)secondary (combined with other type of SIO)–– gen. SIO signs, BUT: bloody diarrhoeagen. SIO signs, BUT: bloody diarrhoea–– palpable intussusceptionpalpable intussusception–– X rayX ray

�� plain: not characteristicplain: not characteristic�� pos. contrast: partial obstructionpos. contrast: partial obstruction

–– USUS–– laparotomy (reducible or irreducible)laparotomy (reducible or irreducible)–– enteroplication (in case of recurrence) enteroplication (in case of recurrence)

�� IntussusceptionIntussusception–– primary (unequal peristaltic moves, enteritis) primary (unequal peristaltic moves, enteritis) ------

puppies and kittenspuppies and kittens–– secondary (combined with other type of SIO)secondary (combined with other type of SIO)–– gen. SIO signs, BUT: bloody diarrhoeagen. SIO signs, BUT: bloody diarrhoea–– palpable intussusceptionpalpable intussusception–– X rayX ray

�� plain: not characteristicplain: not characteristic�� pos. contrast: partial obstructionpos. contrast: partial obstruction

–– USUS–– laparotomy (reducible or irreducible)laparotomy (reducible or irreducible)–– enteroplication (in case of recurrence) enteroplication (in case of recurrence)

IntussusceptionIntussusceptionPlain radiographyPlain radiographyIntussusceptionIntussusception

Plain radiographyPlain radiography

IntussusceptionIntussusceptionPositive contrast radiographyPositive contrast radiography

IntussusceptionIntussusceptionPositive contrast radiographyPositive contrast radiography

IntussusceptionIntussusceptionUSUS

IntussusceptionIntussusceptionUSUS

Types of SIO 2.Types of SIO 2.Types of SIO 2.Types of SIO 2.�� IntussusceptionIntussusception

–– primaryprimary ((unequalunequal peristalticperistaltic movesmoves, , enteritisenteritis) ) ------puppiespuppies and and kittenskittens

–– secondarysecondary ((combinedcombined withwith otherother typetype of SIO)of SIO)–– gengen. SIO . SIO signssigns, BUT: , BUT: bloodybloodydiarrhoeadiarrhoea–– palpablepalpable intussusceptionintussusception–– X X rayray

�� plainplain: : notnot characteristiccharacteristic�� pospos. . contrastcontrast: : partialpartial obstructionobstruction

–– US US (operator (operator dependentdependent, free fluid, , free fluid, linearlinear foreigforeig body)body)

–– laparotomylaparotomy ((reduciblereducible oror irreducibleirreducible))–– enteroplicationenteroplication ((inin casecase of of recurrencerecurrence) )

�� IntussusceptionIntussusception–– primaryprimary ((unequalunequal peristalticperistaltic movesmoves, , enteritisenteritis) ) ------

puppiespuppies and and kittenskittens–– secondarysecondary ((combinedcombined withwith otherother typetype of SIO)of SIO)–– gengen. SIO . SIO signssigns, BUT: , BUT: bloodybloodydiarrhoeadiarrhoea–– palpablepalpable intussusceptionintussusception–– X X rayray

�� plainplain: : notnot characteristiccharacteristic�� pospos. . contrastcontrast: : partialpartial obstructionobstruction


–– laparotomylaparotomy ((reduciblereducible oror irreducibleirreducible))–– enteroplicationenteroplication ((inin casecase of of recurrencerecurrence) )

IntussusceptionIntussusceptionIntraoperative pictureIntraoperative picture




�� Linear foreign body caused obstructionLinear foreign body caused obstruction�� Linear foreign body caused obstructionLinear foreign body caused obstruction


Types of SIO 3.Types of SIO 3.Types of SIO 3.Types of SIO 3.�� LinearLinear foreignforeign body body causedcaused obstructionobstruction

–– youngyoung playfulplayful dog and dog and catcat

–– piecepiece of of stringestringe, , curtaincurtain, , carpetcarpet, , tapetape etc.etc.

–– „„fromfrom thethe oraloral cavitycavity toto thethe anusanus” ! ” !

–– SlowlySlowly deterioratingdeteriorating SIO SIO signssigns

–– abdominalabdominal palpationpalpation is is notnot typicaltypical

–– X X rayray�� plainplain: : roolingrooling upup of of thethe smallsmall intestinalintestinal tracttract

�� pospos. . contrastcontrast: : signssigns of of partialpartial obstractionobstraction


–– laparotomylaparotomy�� usuallyusually multiplemultiple gastrotomygastrotomy//enterotomyenterotomy

�� LinearLinear foreignforeign body body causedcaused obstructionobstruction–– youngyoung playfulplayful dog and dog and catcat








–– laparotomylaparotomy�� usuallyusually multiplemultiple gastrotomygastrotomy//enterotomyenterotomy

LinearLinear foreignforeign body body causedcaused obstructionobstructionExaminationExamination of of thethe oraloral cavitycavity

LinearLinear foreignforeign body body causedcaused obstructionobstructionExaminationExamination of of thethe oraloral cavitycavity

Types of SIO 3.Types of SIO 3.Types of SIO 3.Types of SIO 3.�� LinearLinear foreignforeign body body causedcaused obstructionobstruction









–– laparotomylaparotomy�� usuallyusually multiplemultiple gastrotomiesgastrotomies and and enterotomiesenterotomies










LinearLinear foreignforeign body body causedcaused obstructionobstructionPlainPlain radiographyradiography

LinearLinear foreignforeign body body causedcaused obstructionobstructionPlainPlain radiographyradiography

Linear foreign body caused obstructionLinear foreign body caused obstructionPositive contrast radiographyPositive contrast radiography

Linear foreign body caused obstructionLinear foreign body caused obstructionPositive contrast radiographyPositive contrast radiography

TypesTypes of SIO 3.of SIO 3.TypesTypes of SIO 3.of SIO 3.�� LinearLinear foreignforeign body body causedcaused obstructionobstruction



















Linear foreign body caused obstructionLinear foreign body caused obstructionIntraoperative pictureIntraoperative picture





�� Mesenteric TorsionMesenteric Torsion–– rarely diagnosedrarely diagnosed

–– peracute toxicosisperacute toxicosis--like diseaselike disease

–– deterioration within hoursdeterioration within hours

–– severe SIO signssevere SIO signs

–– characteristic plain X ray signscharacteristic plain X ray signs

–– laparotomylaparotomy–– euthanasia euthanasia







Mesenteric torsionMesenteric torsionPlain radiographyPlain radiography

Mesenteric torsionMesenteric torsionPlain radiographyPlain radiography














MesentericMesenteric torsion (torsion (partialpartial ) ) IntraoperativeIntraoperative picturepicture

MesentericMesenteric torsion (torsion (partialpartial ) ) IntraoperativeIntraoperative picturepicture

MesentericMesenteric torsion (torsion (totaltotal) ) IntraoperativeIntraoperative picturepicture

MesentericMesenteric torsion (torsion (totaltotal) ) IntraoperativeIntraoperative picturepicture


�� Adhesion/Stricture/StrangulationAdhesion/Stricture/Strangulation–– usually as a consequence of previous usually as a consequence of previous

abdominal operations abdominal operations >>1 month 1 month postoperativelypostoperatively

–– mild, slowly deteriorating SIO signsmild, slowly deteriorating SIO signs

–– X rayX ray

–– USUS

–– laparotomy (resection, „shuntlaparotomy (resection, „shunt--anastomosis”) anastomosis”)




–– X rayX ray

–– USUS


Adhesion/Stricture/StrangulationAdhesion/Stricture/StrangulationPlain radiographyPlain radiography

Adhesion/Stricture/StrangulationAdhesion/Stricture/StrangulationPlain radiographyPlain radiography





–– X rayX ray

–– USUS





–– X rayX ray

–– USUS


Adhesion/Stricture Adhesion/Stricture Intraoperative pictureIntraoperative pictureAdhesion/Stricture Adhesion/Stricture

Intraoperative pictureIntraoperative pictureAdhesion/Stricture Adhesion/Stricture


Intraoperative pictureIntraoperative picture






Intraoperative pictureIntraoperative pictureStrangulation Strangulation

Intraoperative pictureIntraoperative pictureStrangulation Strangulation


Strangulation Strangulation Intraoperative pictureIntraoperative picture





�� Paralytic ileusParalytic ileus–– usually secondary to enteritis, pancreatitis, usually secondary to enteritis, pancreatitis,

mechanic obstruction, spinal trauma)mechanic obstruction, spinal trauma)–– gen. SIO signs (“dumb abdomen”)gen. SIO signs (“dumb abdomen”)

–– X rayX ray�� plain: equal intestinal gas accumulation plain: equal intestinal gas accumulation

�� contrast in the stomachcontrast in the stomach

–– conservative treatment (methoclopramide, conservative treatment (methoclopramide, neostigmine, paraffin)neostigmine, paraffin)

–– surgery (intestinal massage)surgery (intestinal massage)







Paralytic ileusParalytic ileusPlain radiographyPlain radiography

Paralytic ileusParalytic ileusPlain radiographyPlain radiography














Small Intestinal PerforationSmall Intestinal PerforationSmall Intestinal PerforationSmall Intestinal Perforation�� As a consequence of delayed mechanic SIO, As a consequence of delayed mechanic SIO,

penetrating external trauma, intestinal tumours penetrating external trauma, intestinal tumours

�� pyloruspylorus--duodenum perforation: side effect of duodenum perforation: side effect of corticosteroids, NSAIDcorticosteroids, NSAID--s s

�� severe SIO signs, peritonitissevere SIO signs, peritonitis�� X rayX ray

–– free gas, fluid in the abdominal cavityfree gas, fluid in the abdominal cavity

–– contrast outside the lumen (barium is forbidden !)contrast outside the lumen (barium is forbidden !)

�� laparotomy (suturing, resection, drainage)laparotomy (suturing, resection, drainage)

�� As a consequence of delayed mechanic SIO, As a consequence of delayed mechanic SIO, penetrating external trauma, intestinal tumours penetrating external trauma, intestinal tumours






Small intestinal perforationSmall intestinal perforationRadiographyRadiography

Small intestinal perforationSmall intestinal perforationRadiographyRadiography

Small Intestinal PerforationSmall Intestinal PerforationSmall Intestinal PerforationSmall Intestinal Perforation�� As a consequence of delayed mechanic SIO, As a consequence of delayed mechanic SIO,

penetrating external trauma, intestinal tumours penetrating external trauma, intestinal tumours






�� As a consequence of delayed mechanic SIO, As a consequence of delayed mechanic SIO, penetrating external trauma, intestinal tumours penetrating external trauma, intestinal tumours






Small intestinal perforationSmall intestinal perforationIntraoperative pictureIntraoperative picture










Surgical procedures on the Small Surgical procedures on the Small Intestine Intestine

Surgical procedures on the Small Surgical procedures on the Small Intestine Intestine

General General surgicalsurgical considerationsconsiderationsGeneral General surgicalsurgical considerationsconsiderations

�� SignificantSignificant septicseptic dangerdanger ((GramGram -- /+)/+)((sterilesterile//contaminatedcontaminated oror contaminatedcontaminated categorycategory, , prophylacticprophylactic iviv. . antibioticsantibiotics))

�� EasyEasy surgicalsurgical availabilityavailability�� Good Good resecabilityresecability („(„shortshort bowelbowel syndromesyndrome”?!)”?!)

�� DoubleDouble drapingdraping and and instrumentationinstrumentation

�� SingleSingle layerlayer interruptedinterrupted ((oror continuouscontinuous) ) closureclosure

�� MonofilamentMonofilament syntheticsynthetic absorbableabsorbable materialmaterial

�� PeritonisationPeritonisation ((omentalisationomentalisation, „, „serosalserosal patch”)patch”)

�� CopiousCopious abdominalabdominal lavagelavage//suctionsuction

�� SignificantSignificant septicseptic dangerdanger ((GramGram -- /+)/+)((sterilesterile//contaminatedcontaminated oror contaminatedcontaminated categorycategory, , prophylacticprophylactic iviv. . antibioticsantibiotics))

�� EasyEasy surgicalsurgical availabilityavailability�� Good Good resecabilityresecability („(„shortshort bowelbowel syndromesyndrome”?!)”?!)

�� DoubleDouble drapingdraping and and instrumentationinstrumentation

�� SingleSingle layerlayer interruptedinterrupted ((oror continuouscontinuous) ) closureclosure

�� MonofilamentMonofilament syntheticsynthetic absorbableabsorbable materialmaterial

�� PeritonisationPeritonisation ((omentalisationomentalisation, „, „serosalserosal patch”)patch”)

�� CopiousCopious abdominalabdominal lavagelavage//suctionsuction

Enterotomy Enterotomy Enterotomy Enterotomy

Surgery of the Small Intestine 1.Surgery of the Small Intestine 1.EnterotomyEnterotomy

Surgery of the Small Intestine 1.Surgery of the Small Intestine 1.EnterotomyEnterotomy

�� Indiction (vital intestine!)Indiction (vital intestine!)–– therapeutic (SIO)therapeutic (SIO)

–– diagnostic (biopsy)diagnostic (biopsy)

�� Surgical techniqueSurgical technique–– preventive antibioticpreventive antibiotic–– double draping, double instrumentationdouble draping, double instrumentation

–– longitudinal incisionlongitudinal incision

–– suturing (single layer, interrupted or continuous)suturing (single layer, interrupted or continuous)

–– peritonisationperitonisation

�� Indiction (vital intestine!)Indiction (vital intestine!)–– therapeutic (SIO)therapeutic (SIO)

–– diagnostic (biopsy)diagnostic (biopsy)

�� Surgical techniqueSurgical technique–– preventive antibioticpreventive antibiotic–– double draping, double instrumentationdouble draping, double instrumentation

–– longitudinal incisionlongitudinal incision

–– suturing (single layer, interrupted or continuous)suturing (single layer, interrupted or continuous)


EnterotomyEnterotomyEnterotomyEnterotomy

EnterotomyEnterotomyEnterotomyEnterotomy EnterotomyEnterotomyEnterotomyEnterotomy

EnterotomyEnterotomyEnterotomyEnterotomy EnterotomyEnterotomyEnterotomyEnterotomy

OmentalisationOmentalisationOmentalisationOmentalisation „Serosal patch”„Serosal patch”„Serosal patch”„Serosal patch”

Surgery of the Small Intestine 1. Surgery of the Small Intestine 1. EnterotomyEnterotomy

Surgery of the Small Intestine 1. Surgery of the Small Intestine 1. EnterotomyEnterotomy

�� Postoperative treatmentPostoperative treatment–– dietdiet

–– antibioticsantibiotics

–– control of intestinal motilitycontrol of intestinal motility

�� ComplicationsComplications–– adhesionsadhesions

–– insuffitiency of sutureinsuffitiency of suture

–– stricturestricture

–– intestinal atonyintestinal atony

�� Postoperative treatmentPostoperative treatment–– dietdiet


–– control of intestinal motilitycontrol of intestinal motility


–– insuffitiency of sutureinsuffitiency of suture



Small Intestinal Small Intestinal Resection and Resection and Anastomosis Anastomosis

Small Intestinal Small Intestinal Resection and Resection and Anastomosis Anastomosis

Surgery of the Small Intestine 2. Surgery of the Small Intestine 2. Resection Resection -- Anastomosis Anastomosis


�� IndicationIndication–– necroticnecrotic sectionsection of of smallsmall intestineintestine

–– ulcerationulceration

–– tumourtumour

–– palliationpalliation („(„shuntingshunting”)”)

�� SurgicalSurgical techniquetechnique–– „„sceletonisationsceletonisation””

–– resectionresection

–– anastomosisanastomosis




–– tumourtumour






Resection Resection -- AnastomosisAnastomosisResection Resection -- AnastomosisAnastomosis

Resection Resection -- AnastomosisAnastomosisResection Resection -- AnastomosisAnastomosis Resection Resection -- AnastomosisAnastomosisResection Resection -- AnastomosisAnastomosis

Resection Resection -- AnastomosisAnastomosisResection Resection -- AnastomosisAnastomosis Resection Resection -- AnastomosisAnastomosisResection Resection -- AnastomosisAnastomosis

Resection Resection -- AnastomosisAnastomosisResection Resection -- AnastomosisAnastomosis Surgery of the Small Intestine 2. Surgery of the Small Intestine 2. Resection Resection -- Anastomosis Anastomosis




–– tumourtumour








–– tumourtumour






OmentalisationOmentalisationOmentalisationOmentalisation „Serosal patch”„Serosal patch”„Serosal patch”„Serosal patch”

Resection Resection -- AnastomosisAnastomosis„Stapler”„Stapler”


Resectio Resectio -- AnastomosisAnastomosis„Stapler”„Stapler”








�� Postoperative managementPostoperative management–– dietdiet


–– checkcheck--up of intestinal motilityup of intestinal motility


–– suture insufficiencysuture insufficiency



�� Postoperative managementPostoperative management–– dietdiet


–– checkcheck--up of intestinal motilityup of intestinal motility


–– suture insufficiencysuture insufficiency



Enteroplication Enteroplication Enteroplication Enteroplication

Surgery of the Small Intestine 3. Surgery of the Small Intestine 3. EnteroplicationEnteroplication


�� IndicationIndication–– recurrent invaginationrecurrent invagination

�� Surgical techniqueSurgical technique–– „serpentine„serpentine--like” intestinal configurationlike” intestinal configuration

–– seromuscular stichesseromuscular stiches

�� IndicationIndication–– recurrent invaginationrecurrent invagination

�� Surgical techniqueSurgical technique–– „serpentine„serpentine--like” intestinal configurationlike” intestinal configuration

–– seromuscular stichesseromuscular stiches

EnteroplicationEnteroplicationEnteroplicationEnteroplication



�� PostoperativePostoperative managementmanagement–– pulpypulpy dietdiet

–– keepkeep awayaway fromfrom bonebone and and drydry foodfood

�� ComplicationsComplications–– relativelyrelatively frequentlyfrequently inin a a studystudy

–– obturatioobturatio, , strangulatiostrangulatio, , perforatioperforatio, , peritonitisperitonitis, , temporarytemporary hypomotilityhypomotility

�� PostoperativePostoperative managementmanagement–– pulpypulpy dietdiet

–– keepkeep awayaway fromfrom bonebone and and drydry foodfood

�� ComplicationsComplications–– relativelyrelatively frequentlyfrequently inin a a studystudy

–– obturatioobturatio, , strangulatiostrangulatio, , perforatioperforatio, , peritonitisperitonitis, , temporarytemporary hypomotilityhypomotility

Surgery of the Small Intestine - kisallatsebeszet.hu of the Small Intestine Dr. T. Németh, DVM, PhD...

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Transcript of Surgery of the Small Intestine - kisallatsebeszet.hu of the Small Intestine Dr. T. Németh, DVM, PhD...