Small bowel resection and anastomosis

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• anastomotic leak needing reoperation or a stoma
• stoma if the bowel ends are not safe to join
• intra-abdominal collection or abscess
• wound infection, burst abdomen and later hernia
• prolonged ileus
• short bowel problems (diarrhoea, poor absorption) if a long segment is removed
• further obstruction from adhesions
• ICU stay and risk to life in sick patients

Pre-operative details for this operation

1. IndicationStrangulated / gangrenous bowel (adhesion, band, hernia, volvulus)Mesenteric ischaemiaMultiple perforations (trauma, typhoid, TB)Stricture (TB, Crohn disease)TumourIntussusception
2. Duration of symptoms and signs of strangulationhours of pain, vomiting, distension, tenderness, fever, tachycardia, raised lactate
3. ImagingX-ray (air-fluid levels), CT findings
4. ResuscitationIV fluids, NG decompression with aspirate volume, urinary catheter and output
5. Blood resultsHb, TLC, urea, creatinine, sodium, potassium, lactate / ABG
6. Stoma site markedMarked (in case needed)Not marked (reason)

Anaesthesia and position

1. AnaesthesiaGA with rapid sequence intubationGA with epidural
2. PositionSupine
3. Lines and tubesNG tube, Foley catheter, central line if placed

Operative findings

1. Peritoneal fluidvolume, type (clear, blood-stained, foul, faeculent)
2. Causeband, adhesions, internal hernia, volvulus, stricture, mass, perforations
3. Affected segmentjejunum / ileum, length in cm, distance from DJ flexure and from ileocaecal junction
4. ViabilityGangrenousDoubtful, improved after release and warm packsViablecolour, sheen, peristalsis, mesenteric pulsation, bleeding
5. Proximal and distal boweldilated / collapsed, wall oedema, diameter mismatch
6. Rest of abdomenwhole small bowel run from DJ flexure to ileocaecal junction; colon, hernial orifices, other findings

Procedure (steps)

1. IncisionMidlineHernia incision with laparotomyLaparoscopic assistedlength
2. Cause dealt withband divided, adhesiolysis, hernia neck released, volvulus untwisted
3. Viability assessed after releasewarm moist packs, 100% oxygen, time waited (e.g. 5 to 10 min), result
4. Bowel decompressedMilked back to NG tubeThrough the resected end with suckerNot needed
5. Resection marginsin healthy bowel; length resected in cm; wider margins with mesentery for tumour
6. Mesentery dividedV-shaped, vessels ligated with silk 3-0 or energy device
7. Cut-end viabilitypink mucosa, bright red bleeding from cut edge; ends trimmed back if dusky
8. Type of anastomosisEnd-to-endSide-to-side (functional end-to-end)End-to-side
9. TechniqueHand-sewn single layer interrupted extramucosalHand-sewn two layer (inner continuous, outer interrupted Lembert)Stapledsuture material and size, e.g. polyglactin 910 (Vicryl) 3-0 or silk 3-0; bite and spacing about 5 mm; stapler type and cartridge
10. Diameter mismatch correctedNot neededCheatle cut on antimesenteric border of narrow endOblique division
11. Anastomosis checkedpatency between finger and thumb, no tension, no twist, pink ends
12. Mesenteric defect closedYes, interruptedYes, continuous
13. Length of remaining small bowelmeasured along antimesenteric border, in cm (write it when a long segment is removed)
14. Stoma instead of anastomosis (if done)reason (peritonitis, shock, doubtful viability), type and site
15. Peritoneal lavage and omentumwarm saline volume; omentum placed over anastomosis

Closure, drains and dressing

1. DrainNoneTube drain (site)
2. FasciaSmall bites: continuous 2-0 polydioxanone (PDS)Mass closure: continuous looped No. 1 PDSSmead-Jones
3. SkinInterrupted suturesSubcuticularLeft open (heavy contamination)

Specimens and implants

1. Resected bowel sent for HPEYeslength, proximal end marked, clinical details on form (TB / tumour suspicion)
2. Peritoneal fluid for cultureSentNot sent
3. Stapler usedmake, type, cartridge size and lot sticker, if stapled

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Monitoringpulse, BP, temperature, urine output; frequency; ward / HDU / ICU
2. Nil by mouth and NG tubefree drainage and aspiration; removal when output falls and bowel sounds return
3. IV fluids and electrolytestype and rate; daily sodium, potassium, creatinine
4. Antibioticsprophylaxis only (under 24 hours) or treatment course, with drug and dose
5. Analgesiadrug, dose, frequency; epidural if placed
6. Oral intakestart when flatus passed and abdomen soft
7. Watch for leakfever, tachycardia, abdominal pain, drain or wound discharge from day 3 onwards
8. Thromboprophylaxis and chest physiotherapystockings, LMWH, spirometry, early mobilisation
9. Follow-upHPE report; nutrition review if long segment removed

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery