Always “run” the entire small intestine before any resection. Grasp a section of small bowel and pass it from one hand to the other, “walking” your fingers proximally. You should be progressing in the general direction of the left upper quadrant. Identify the suspensory ligament of duodenum (ligament of Treitz). Progressing distally from the ligament of Treitz, elevate a section of small bowel about 10 cm in length. Flip each section over so that both sides are examined. Then pass the section to your first assistant. Continue in this fashion to the ileocecal valve. If, by chance, the loop of bowel that you grasp in the beginning leads you to the ileocecal valve instead of the ligament of Treitz, it is perfectly acceptable to run the bowel from distal to proximal, finishing at the ligament of Treitz. Minimize the amount of time that the bowel is out of the abdomen. Interference with venous drainage, swelling, and hypothermia can result from prolonged evisceration. Return all bowel, with the exception of the segment to be resected, to the abdomen.

Grasp the bowel between the thumb and the forefinger of your nondominant hand and use your thumb to feel the mesenteric border of the bowel at one of the planned resection margins. Take a fine-pointed mosquito hemostat and pass it under one of the small vessels that supply the bowel. Double clamp and ligate the vessel with fine silk. Do not try to break through on your first pass unless the mesentery is very flimsy. Divide the mesentery close to the bowel with precision to minimize the bulk of tissue included in ligatures next to the bowel. The mesenteric surface of the bowel will then be clean and ready for anastomosis.

Clamp the bowel with Allen clamps or similar straight clamps designed to hold bowel securely. Kocher clamps will work if nothing else is available. Divide the bowel between the clamps with a scalpel.

Repeat this process at the other end of the segment to be resected.

Lift the bowel up to display the mesentery and identify the line along which you plan to resect it. With the mesentery slightly stretched, place the opened blade of a pair of Metzenbaum scissors into the incision in the mesentery and lift up, elevating a flap of peritoneum with the tip of the blade. Push-cut the peritoneum by pushing with the crotch of the barely opened scissors, outlining a V-shaped segment of mesentery to be resected. This cut should not injure the underlying mesenteric vessels. Flip the bowel over and do the same thing on the other side of the mesentery. Use the thumb and forefinger of your nondominant hand to elevate the thin, fatty mesentery. A finger fracture technique is sometimes useful. Double clamp and divide all mesenteric vessels, and remove the resected segment.

Secure the mesenteric vessels with suture ligatures of 3-0 silk.

Running the bowel allows the surgeon to inspect the entire length of small bowel for disease or incidental developmental anomalies. The most common anomaly is Meckel diverticulum, which has been reported to be present (although is usually asymptomatic) as frequently as 4.5% of the time.

The ligament of Treitz, or the suspensory muscle of the duodenum, marks the beginning of the intraperitoneal jejunum. This ligament is present about 75% of the time. A band of smooth muscle running from the connective tissue around the celiac artery and right diaphragmatic crus blends with smooth muscle at the duodenojejunal flexure. It has little significance as a muscle, but functions as a ligament to maintain the duodenojejunal flexure. However, because it is muscular and thus vascular, division of this ligament, if necessary, must be done between clamps and with appropriate hemostatic control.