Small Bowel Diseases

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.

Schematic of the Small Bowel

The diseases of the small bowel for which surgery may be required include:

  • Tuberculosis
  • Obstruction (blockage)
  • Benign tumors
  • Carcinoid tumors
  • Malignant (cancerous) tumors

The symptoms of small bowel disease vary depending on the site and type of the pathology. They include

  • Cramping abdominal pain, often in the centre
  • Nausea & vomiting
  • Loss of appetite and weight loss
  • Rectal bleeding

Often the patients present with acute intestinal obstruction or blockage in the small bowel caused by adhesions or a narrowing (stricture) caused by tuberculosis.

Many of the symptoms of small bowel disease are also present in other, more common, diseases. This can make diagnosis of small bowel problems difficult.After a detailed history and physical examination tests to visualize the small bowel are usually required.

These tests may include:

Barium series or small bowel enema: In this tests the patient is either given liquid barium to drink or this is introduced into the small bowel in a controlled manner via a thin tube placed through the nose. Multiple x-rays are then obtained to follow the passage of the barium through the intestinal loops and identify the area of the problem.
CT scan: A CT scan is obtained after the patient drinks a liquid contrast material. This helps identify the location and nature of the small bowel pathology.

A small bowel tumor seen on a barium study

A small bowel stricture seen on a barium stud

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.

As the small bowel is some 18 – 20 feet long in adults, often these tests fail to pinpoint the site of pathology. In the past a patient required an “exploratory laparotomy” or an open operation using a long incision to check the whole of the small bowel. Today, often the same can be achieved by a laparoscopic operation. The surgeon makes a small (about 1-cm) incision and places a short tube called a cannula through the abdominal wall. This cannula is connected to a special pump that pumps carbon dioxide gas. As the abdomen gets filled up with the gas, the abdominal wall is lifted up, thus providing the surgeon a space to work in. To look inside the abdomen, the surgeon passes a rod-like telescope through the cannula. The telescope is connected to a miniature video camera that picks up the picture of the inside of the abdomen and transmits it to a television screen. The surgeon then carries out the operation with the help of special, long instruments introduced inside the abdomen through other cannulas and by observing the picture of the operative site on the television screen. It is possible to carefully examine whole of the small bowel loop by loop and identify the site of the problem. One of the small incisions is then extended to bring out the diseased segment of small bowel, excise it and joins the ends back. The small bowel is then placed back in the abdomen and the small incisions are closed. Alternately, the diseased segment may be resected and the healthy ends rejoined inside the abdomen using special staplers and then retrieved through a small incision

Narrowing in small bowel identified at laparoscopy

Diseased segment of small bowel brought out before resection

In a single incision laparoscopic surgery (SILS), the surgeon makes only one incision inside the navel and places all three cannulas or tubes through this. The entire small bowel is traced as described above and the diseased portion is brought out and excised in a similar manner.

Single incision laparoscopic surgery for small bowel disease

Invisible scar of single incision laparoscopic resection of small bowel

The surgeon would assess an individual patient to decide whether or not he / she are a suitable candidate for SILS. SILS may not be applicable to some patients, e.g.

  • Those who are very obese,
  • Those who have an acute intestinal obstruction and gross distention of small bowel reducing the working space inside the abdomen
  • Those who have had multiple previous abdominal operations and

Traditional laparoscopic surgery, of course, can be offered to all these groups of patients.

In 5% to 10% patients it may not be possible to complete the operation by SILS due to technical difficulties. The surgeon places one or two additional ports and completes the procedure in the traditional laparoscopic manner. Very rarely, it may be necessary to convert to an open operation. Both these issues are always discussed with patients prior to surgery and they are made aware that conversion to traditional laparoscopy or indeed to open surgery merely represents a sound judgment on part of the surgeon in the interest of patient safety.

  • Less pain from the incisions after surgery
  • Shorter hospital stay
  • Shorter recovery time
  • Faster return to normal diet
  • Faster return to work or normal activity
  • Better cosmetic healing

Publications and abstracts

  1. Bhandarkar DS, Shah RS. Gallstone ileus. Gastrointest Endosc 2003; 57: 720.

Presentations, invited lectures & videos

  1. Punjani RM, Bhandarkar DS, Shah RS. Laparoscopy in management of disease of the small bowel. Annual Conference of Maharashtra Chapter of ASI, Nasik, 2002.
  2. Bhandarkar DS, Shah R, Sen G. Laparoscopically assisted enterolithotomy for gallstone ileus. 5th Annual Conference of IAGES, Kolkata, 2002.
  3. Bhandarkar DS, Shah R, Sen G. Laparoscopically assisted enterolithotomy for gallstone ileus. Annual Conference of Maharashtra Chapter of ASI, Nasik, 2002.
  4. Bhandarkar DS, Punjani RS, Shah RS. Laparoscopy in management small bowel disorders. Annual Scientific Sessions, College of Surgeons of Sri Lanka, Colombo, 2002.
  5. Bhandarkar DS. Laparoscopic surgery for small bowel disorders. Conference on Basic & Advanced Minimal Access Surgery, Indore, 2003.
  6. Bhandarkar DS. Minimal access surgery for small bowel disorders. IAGES 2008, Jaipur, 2008.

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