The small bowel forms the majority of “real estate” particularly in the lower abdomen and remains to this day one of the most formidable challenges that a laparoscopic surgeon faces when he is performing surgery [1]. The common conditions that will require the laparoscopist attention includes.

  1. 1.

    Blockages either due to adhesions or are congenital.

  2. 2.

    Bleeding, infection, and ulcers due to disease process, i.e., Chron’s disease.

  3. 3.

    Cancer and carcinoids.

  4. 4.

    Small bowel injury.

  5. 5.

    Meckel’s Diverticulum.

  6. 6.

    Precancerous polyps.

  7. 7.

    Non-cancerous benign tumors.

Inadvertently the most common reason for a small bowel resection would be adhesions [2]. For simplification purposes, this part will focus on acquired and not congenital issues which need small bowel resections.

Almost all small bowel resections can be done by laparoscopy [1]. If the patient is fit for general anesthesia, they should be fit for a laparoscopic resection option as well. Absolute contraindication for resection would include

  • Poor blood supply to bowel ends (i.e., radiation-injured bowel).

  • Unclear bowel viability after a revascularization procedure.

    • Both ends of the small bowel may be brought up to skin level as temporary ostomies if the distal small bowel is involved. A proximal small bowel ostomy will create a high-output fistula that is difficult to manage.

    • Alternatively, both ends can be stapled closed and a plan made for a second-look laparotomy in 24–48 h.

    • In extreme situations (e.g., acute mesenteric ischemia with gangrene extending from the ligament of Treitz to mid colon), the likelihood of survival is very small. This is an absolute contraindication to attempted resection and anastomosis [3].

  • Inadequate tumor margins.

    • If a tumor is unresectable, and small bowel obstruction is likely to occur, a side-to-side anastomosis in the uninvolved bowel proximal and distal to the obstruction may be performed as a bypass procedure, leaving the tumor in situ.

Relative Contraindications Would Include

  • Peritoneal sepsis.

  • Hemodynamically precarious patient.

  • Extensive Crohn’s disease.

    • Stricturoplasty should be considered to minimize the need for extensive resection and the risk of short gut syndrome; 90 cm is the approximate shortest length of small bowel that might still support a viable oral nutrition program.

The limiting factor is however the operator. The resection requires an experienced surgeon whereby some suggest the experience should be at least someone who is able to perform intracorporeal knotting and suturing comfortably. The other requirement is the knowledge of patient orientation and usage of the operating table including the functions of rotations and various positions. The small bowel is a precarious organ that flops around and good control over the mobility of the organ is essential.

Preoperative assessment is a vital step in performing small bowel resections [3]. The availability of information regarding the location of pathology, nature of pathology, and the extent of contamination would affect the positioning of the patient and also placement of trocars. A contrast CT scan would be able to show the nature of the pathology and also avail information regarding contamination if present. This would then be translated into planning the operation itself. In laparoscopic small bowel resection, the consideration should be if the operator is required to stand in between the patient’s legs in either a Trendelenburg or reverse Trendelenburg position (Fig. 1).

Fig. 1
Three images of a patient on an operating table. Image A is labelled split leg; the patient is resting down on the table, his legs spread apart, and the table is straight. Image B is labelled Trendelenburg because the table is tilted with the head higher than the head. Image C is labelled reverse Trendelenburg, as the head is higher than the feet.

Split leg, trendelenburg, and reverse trendelenburg position

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It is my contention that if the pathology is located in the upper small bowel, i.e., the duodenum or the jejunum it would be better to position the patient in a head-down position with the operator standing between the patient’s legs. However, if the pathology is located in the lower small bowel, i.e., a Meckel’s diverticulum, the operator should be standing on either side of the patient with a slight tilt up on the opposite side (Fig. 2).

Fig. 2
Two depictions of doctors and patients during an operation. The doctor is in between the patient's legs in Image A, and the first and second assistants stand on either side of the patient. Image B shows the surgeon and two assistants standing on the right side of the patient.

Surgeon standing in between legs or on either side of the patient

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The patient should be catheterized if the operation is expected to take some time, i.e., more than 90 min and there should be considerations for DVT prophylaxis according to local norms and practices. Prophylactic and empirical antibiotics are also as per local norms and practices. Other imaging modalities that can be used to aid are as follows:

  • Small bowel follow-through and small bowel enteroclysis.

  • As indicated for bleeding:

    • Esophagogastroduodenoscopy, push enteroscopy, or double balloon enteroscopy.

    • Capsule endoscopy.

    • Nuclear scan.

    • Angiography.

The three positioning for port placement for patients for small bowel surgery is illustrated in the diagram below (Fig. 3). The placement of ports and selection of port placement should be dictated by the pathology itself. As mentioned before a CT scan is essential in this regard. The aim is to not only triangulate the pathology and working space ergonomically but also to ensure that adequate room is available for not only resection but also to accommodate stapler devices and aid in closure using intracorporeal sutures. The likely positions for port placement are illustrated below. The most general consideration would be for adhesions. The pathology does not allow very much planning but in general I prefer to place a supraumbilical port by an open technique followed by diagnostic laparoscopy before inserting the other ports. Once the adhesiolysis is undertaken, the working port can be enlarged to accommodate the stapler device and aid in resection and closure.

Fig. 3
An instance of an ongoing operation. The doctor has two probes placed into the patient's abdomen while the patient's belly is exposed. A different tube-shaped device is inserted just above the belly button, and the monitor is positioned a few inches away from the patient's hand.

Triangulate pathology during port placement

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Surgical Technique and Synthesis

Small bowel resections laparoscopically are always a balance of finesse and precision [2]. The operator has to determine the viability of the segment that remains and how much of the small bowel is actually going to be resected. The consideration is further confounded by the general condition of the patient, i.e., is the patient septic or bleeding due to an injury. Once the affected segment is identified, the surgeon has to perform a detachment procedure whereby the small bowel is denuded of the blood supply. Often an energy device is used for this purpose and the author’s preference is the Ligature device from Medtronic or the Harmonic Ace by Johnson and Johnson. The addition of separating the function of sealing and cutting allows more control when performing this step. Often however the operator can get carried away by the ease of the instrument and fail to dissect clear and large vessels before sealing them and this will lead to obscurity of vision and unexpected bleeding.

Once the segment of the bowel is denuded from the blood supply the resection is undertaken. It is often done with staplers and the height required depends on the thickness of the tissue however in general a stapler device using a height of 2.6–3.6 mm is sufficient for the job. It is essential for the operator to place the segment of resection away from the trocar site for this step to aid in resection and then anastomoses. Another important tip is to use an anchoring stitch to keep the two bowel segments together before stapling for the anastomoses. In general, we can use three staples, i.e., two for the resection ends and one for the anastomosis or anastomose first and then resect which will usually always end with three staples as well. The former technique requires closure of the enterotomy created by the stapler insertion and the latter does not.

The closure of the omental defect after performing small bowel resection is debatable however it is the author’s opinion that all defects should be closed and the closure of this defect is relatively easy to perform. Drains are not routinely recommended.

Postoperative Management and Complication

Post surgery the patient can be started on clear fluids almost immediately in ward and following bowel movement, up-scaled to a nourishing and normal diet. There is a lot of evidence to support the fact that bowel movements are faster after laparoscopic bowel resections as opposed to open surgery however the overall postoperative stay may not be affected. There is no need for the continuation of antibiotics unless there has been evidence of contamination or infection during the surgery and patients are encouraged to ambulate and mobilize as soon as possible.

Common Complications Include

  • Surgical site infection (either deep or superficial).

  • Bleeding.

  • Systemic complications of major surgery, including pneumonia, venous thromboembolism, and cardiovascular events.

    • Small bowel obstruction, stricture, and the need for further surgery are also potential risks of small bowel resection.

    • Patients with extensive intra-abdominal sepsis or who are in a malnourished state are at increased risk for anastomotic leak and enteric fistula.

In summary, small bowel resection is a delicate and precise procedure that can be undertaken safely by laparoscopy.