Injury to the small intestine may occur during difficult operations; this is especially true of operations in the pelvis for neoplastic or inflammatory diseases, in endometriosis, or when there have been previous multiple surgeries. Injuries vary from partial to through-and-through small or large lacerations, perforations, monopolar or bipolar burn injuries, and avulsion injuries to the mesentery and hemorrhages. Success in management of these complications depends on their immediate recognition and treatment. Failure or delay in identifying these injuries may lead to other more serious complications.
1. Laceration injury to small bowel
a. After proper local hemostasis, irrigation, and debridement, the bowel may be closed safely with interrupted nonabsorbable sutures. It is closed transversely according to the Heineke-Mikulicz principle.
b. Large lacerations or multiple small lacerations in the same segment are treated with a limited resection and an end-to-end anastomosis,
c. Lacerations to the mesenteric border, unless they are quite small, are difficult to repair and may be associated with vascular impairment. When in doubt of the vascular integrity, a resection should be undertaken. Antibiotic coverage should be used accordingly in relation to the degree and duration of local contamination.
2. Perforation injury to small bowel
a. Sharp and small perforations, such as those inflicted by the Veress needle used in laparoscopy, are self-limited and may require a small purse-string closure if leakage is confirmed.
b. Sharp and large perforations such as those inflicted by primary and secondary laparoscopic trocars need a careful local assessment and immediate primary closure using interrupted, nonabsorbable suture material. As in all penetrating or stab wounds of the bowel, ideally the trocar or sleeve should not be removed to facilitate location and repair of single, through-and-through and multiple puncture injuries to the bowel.
3. Thermal injury to small bowel
a. The most serious injury is the one caused by monopolar energy with necrosis of the bowel wall beyond the area of actual perforation. If a persistent blanched area or a blanched area around a perforation is found, resect at least 5 cm of bowel on either side of the injury. Examine minutely for active bleeding from the wound edges after debridement or resection before local repair or bowel anastomosis is done. Active bleeding from the wound edges indicates healthy blood supply that is necessary for optimal healing, b. Wound resection adequate to reach viable tissue is less extensive after a bipolar or a laser energy burn to the bowel. Nevertheless, the surgeon is encouraged to resect and debride the injury until there is active bleeding from the wound edges before proceeding to local repair or bowel anastomosis as needed.
4. Avulsion injury to mesentery: Avulsion injuries usually occur from undue traction exerted on the mesentery. Copious bleeding is the most troublesome. Safe control of the hemorrhage requires adequate exposure and visualization. The surgeon can confidently and deliberately control the exact bleeding point without resorting to the use of mass suture ligatures or thermocoagulation. It is better to provide local tamponage, for a few minutes, with steady finger pressure to the bleeding area or by means of a small pack. The bleeding will have ceased and individual ligation of lacerated blood vessels can be done. Repair of large and important veins may be necessary.