Laparoscopic Small Bowel Surgery
What is the small bowel?
The small bowel, or small intestine, consists of a flexible tube many feet long that starts at
the stomach and ends in the colon. Its surface absorbs water and nutrients from food.
Diseases
Surgical diseases that affect the small bowel include:
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Crohn’s Disease
Obstruction (blockage)
Tumors (growths)
o Carcinoid Tumors
o Adenocarcinoma
o Benign tumors
Symptoms
Symptoms of small bowel disease include rectal bleeding, cramping, nausea, abdominal
pain, and weight loss, among others.
Diagnosis
Most of the symptoms of small bowel disease are also present in other, more common,
diseases. This can make diagnosis of small bowel problems difficult. Your doctor will start
with a detailed history and physical exam. Other studies may include:
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CT scan
Upper GI series with small bowel follow through (x-rays following liquid barium
through the intestines)
Endoscopy – Endoscopy involves passing a long tube with a light and camera down
the throat or through the anus (colonoscopy). The small bowel is so long that it is
difficult to see all of it this way, but advances are being made that allow a better look
at the small bowel. This includes “capsule endoscopy” in which a tiny camera is
swallowed in a pill. It takes pictures of the small bowel as it passes through and
radios them out to a computer where your doctor can look at them.
Treatment options
While Crohn’s disease can often be treated (at least initially) with medicines, obstruction
and tumors usually require surgery. Traditionally, operations on the small bowel required a
large abdominal and/or pelvic incision, which often required a lengthy recovery. New
instrumentation and techniques allow the surgeon to perform the procedure through several
small incisions, what we now refer to as “minimally invasive”, “laparoscopic”, or
“laparoscopic-assisted” surgery.
Description
Minimally invasive or laparoscopic surgery involves using multiple trocars (thin tubes)
placed through 3 to 5 small incisions. These incisions are usually less than 0.5 cm (less than
¼ inch). Carbon dioxide gas is then used to slowly inflate the abdomen. A thin telescope is
placed through one of the trocars. This allows the surgical team to view the inside of the
abdomen on a TV monitor. Specialized instruments are placed through the other trocars to
perform the operation. For small bowel surgery, one of the incisions is enlarged to remove
the piece of bowel. This larger incision can also be made initially, allowing one hand to be
placed within the abdomen along with the camera and long instruments to assist with the
operation. The procedure is performed under general anesthesia.
Advantages
Results are different for each procedure and each patient. Some common advantages of
minimally invasive colorectal surgery are:
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Shorter hospital stay
Shorter recovery time
Less pain from the incisions
Faster return to normal diet
Faster return to work or normal activity
Better cosmetic healing
Many patients qualify for laparoscopic or minimally invasive surgery. However, some
conditions may decrease a patient’s eligibility, such as previous abdominal surgery, cancer
(in some situations), obesity, variations in anatomy or advanced heart, lung or kidney
disease.
Before Surgery
Before you go to surgery, you will need to be evaluated by your primary doctor and your
surgeon. You may need further tests such as a colonoscopy, barium enema, EKG, chest xray, CT scan of the abdomen, and/or blood work. Your surgeon or primary doctor will order
these tests.
Small bowel surgery may require some form of bowel preparation. A bowel preparation
should be followed by only a liquid diet and no solids for 8 hours prior to surgery. You may
be instructed to stop taking certain home medications. These include blood thinners,
warfarin, aspirin and ibuprofen. You should notify your surgeon of ALL current medications
during your evaluation
Patients are usually admitted to the hospital the day of surgery.
During Surgery
You will meet with the anesthesiologist and an intravenous catheter will be placed in your
arm for delivery of fluids and medication during your surgery. This procedure is performed
under general anesthesia, which means you will be completely asleep. As soon as you are
asleep, catheters are placed through the nose into the stomach and in the bladder and the
surgical team will work together to perform the operation. Monitors are used to observe
your vital signs throughout the surgery. When the operation is complete the breathing tube
is removed. Most patients do not remember this. You are then taken to the recovery room
for a short stay.
After Surgery
After your surgery is done, you will be taken to the Post-Anesthesia Care Unit, or PACU. You
will be there for 1-2 hours. When you are ready, you will be moved to your hospital room
where your family will be able to see you. The nurses will continue to check your heart rate,
blood pressure, temperature, breathing and your incision.
They will also be checking your tubes:
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NG to drain your stomach. This is sometimes removed in the operating room but
otherwise will stay in for about 1-4 days.
Foley catheter to drain your urine. This stays in for 2-3 days.
IV for fluids and medicine. This will stay in until you are able to eat again.
For pain control, there may be a pump attached to your IV. This is called a PCA or patient
controlled analgesia pump. You will have a button that you push when you start to feel it’s
time for pain medicine. The pump is set so that you cannot get too much medicine. Often
you will use this pump until you are able to eat and take pain medicine by mouth.
The compression devices will stay on your legs while you are in bed during your
hospital stay to lessen your risk of blood clots.
Your activity
That afternoon or, at the latest, on the first day after your surgery, you will be helped out of
bed to sit in a chair. By the second day, you will need to walk in the hallway. Walking helps
lessen your risk of getting a lung infection or blood clots. It also speeds up your recovery.
Nutrition
You will not be able to eat or drink anything at first. You may be given some ice chips at
times. Once the NG tube is removed, you will start on a clear liquid diet the next day. Your
diet will be changed each day, as you are better able to eat foods.
Complications
Complications are possible with any surgical procedure. The following are some
complications related to laparoscopic small bowel surgery:
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adverse reaction to anesthesia
bleeding in the abdomen
infection in the abdomen or wounds
intestinal obstruction due to scar tissue
leakage from the bowel
heart attack or pneumonia
blood clots in the legs or lungs
injury to other organs
If the operation cannot be completed laparoscopically, the surgeon will make a traditional,
larger incision. Reasons for this include bleeding and the inability of the surgeon to clearly
view the operative area. This should never be considered a failure, but rather a prudent
decision by the surgical team to safely complete the operation.
Discharge
You will be able to leave the hospital when you are:
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Able to eat a regular diet and drink fluids
Passing gas or you have had a bowel movement
Passing urine
Not having a fever or other signs of infection
Walk for short distances
Most people are able to go home 4-7 days after their surgery.
After Discharge
These guidelines give you an overview of what you may expect as part of your
care after you leave the hospital. Be sure to follow your doctor’s discharge
instructions if they are different from what is listed here.
Your activity
It is fairly common to feel weak and tired immediately after discharge from the hospital. The
body needs time to recover from the stress of a major operation.
Walking
walking is permitted and encouraged beginning the next day after surgery. At home, start
short, daily walks and gradually increase the distance you walk.
Climbing
Going up and down stairs is permitted. Initially, have someone assist you.
Lifting
You may lift light objects (less than 10lbs.) after your discharge. This may be increased
gradually after one month. If lifting an object causes discomfort, you should discontinue the
activity. This restriction helps prevent hernias at the sites of your incisions.
Showers
Showers are permitted 2 days after surgery. Wash over your incisions gently with soap and
water. Be careful to rinse well. Pat the incisions dry.
Driving
Driving is not permitted for 2 weeks after surgery or your first follow-up visit with your
surgeon. If you are taking prescription pain medications or narcotics, DO NOT DRIVE.
Sex
Sexual intercourse may be resumed as your comfort level permits.
Return to work
People with sedentary jobs have returned to work as early as two weeks postoperatively. A
physically demanding job may require 4-6 weeks before returning to work. This may be
determined by you and your employer. Some people have residual fatigue several weeks
after surgery.
Your bowel habits
You may have different bowel habits after your surgery. Loose stools are common for the
first week or two after surgery. If you have watery diarrhea, call your surgeon. This may be
a sign of a bowel infection. Severe constipation should be avoided. See the section below on
medicines for constipation.
Your diet
There are generally no dietary restrictions following surgery. Avoid foods that cause
diarrhea or digestive discomfort. You will eventually be able to resume your regular diet. A
dietary supplement or drink can be used.
Medications
Your medicines: Take the medicines you were taking before surgery, unless your doctor has
made a change.
For pain
Your surgeon will order a prescription pain medicine for you after surgery. As your pain
lessens, over the counter pain medicines such as acetaminophen (Tylenol) or
ibuprofen (Advil) can be used. They can also be used instead of your prescription for mild
pain.
For constipation
Prescription pain medicines can cause constipation. Your doctor may order docusate
(Colace) as a stool softener to prevent this. You should be back to your normal bowel
routine in about 2 weeks. If the stool softener does not work, take Milk of Magnesia. If you
still are not getting relief, call your surgeon.
Call your doctor's office right away if you have:
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Diarrhea that lasts more than three days
Nausea and vomiting that will not go away
Pain in your abdomen that gets worse or isn’t eased by the pain medicine
Pus drainage or redness around your incision
Fever with a temperature of 100.5 or higher
Follow-up
In order to identify and treat any complications as they may arise, close, lifetime follow-up
is essential. Follow-up after surgery is extremely important. Patients usually make an
appointment to see their surgeon 2 weeks after discharge. At this visit, further plans are
made and the patient may be cleared for full activities such as driving.