Anastomotic technique, gastrointestinal, end-to-end, open, continuous, hand suture, rotation technique

You have not purchased a license - paywall is active: to the product selection
  • Praxis für Handchirurgie und Handgelenkchirurgie Frankfurt

    Dr. med. Kirsten Beyermann

Single Access

Access to this lecture
for 3 days

€4.99 inclusive VAT

payment

webop-Account Single

full access to all lectures
price per month

for the modul: vascular surgery

from 8,17 €

hospitals & libraries

for the modul: vascular surgery

from 390,00 euros

  • Anatomical principles

    Large and small intestine have a very similar wall structure. The reduced mechanical strength of strictly mucosal sutures stems from the small amount of connective tissue and collagen fibers in the mucosal layer.
    Comprising connective tissue with a three-dimensional collagen fiber lattice and elastic meshes, the submucosa constitutes the “load-bearing” part of the intestinal sutures in all parts of the digestive tract. The muscularis layer is also a reliable suture line, and the serosal covering allows for a gas- and fluid-proof seal as a result of fibrin exudation within just 4-6 hours after intestinal suturing.

    The large intestine plays a special role here. Its complication rate is higher because of various characteristics. This is due to low collateral circulation, the lack of serosal covering on parts of the ascending and descending colon and on the entire extraperitoneal rectum, and a lower mural collagen concentration in the large intestine with higher collagenase activity. In addition, since the concentration of bacteria increases by a factor of 10 million, there is a greater risk of infection. And anaerobes are 1,000 times more common in the large intestine than aerobic bacteria.

  • Physiological principles

    Leak-proof anastomosis by secure suturing is an indispensable part of abdominal surgery. All gastrointestinal sutures have two objectives: First, to restore a liquid- and gas-proof inner layer with the least ischemic effect possible on the transection margins. And secondly, to ensure resistance to all physical stresses and strains such as fluctuating intraluminal pressure, peristalsis, longitudinal tension and external pressure from adjacent organs. All of this should take place using a simple and rapid technique with the goal of minimizing contamination of the surgical field and implanting as little of the best tolerated foreign body material as possible.

    Suture material causes foreign body reactions in the tissue; it supports and impairs healing at the same time. Animal studies on burst pressure confirm that the strength of an anastomosis decreases until the fourth day and then increases once again until normal levels are reached at around day 10.

    Nevertheless, the suture material still acts as a foreign body that delays healing and increases the risk of pathogen infection. There are various options for decreasing this foreign body irritation Minimizing the mass of suture material to be implanted, use of absorbable substances persisting only for the duration of the actual load bearing function, and use of materials with only a low potential for irritation.

    As with other wounds, intestinal anastomoses heal in three phases, . Lasting until day 4, the first phase is characterized by exudation of fibrin and blood components. During this time, the mechanical strength of the suture depends on the suture material used. In the second phase, from day 4 to 14, vascular and fibroblast proliferation dominates. During the next phase of several months, the layers of the intestinal wall will reorganize.

  • Technical principles

    Most gastrointestinal sutures had been developed as interrupted sutures (Jobert, Lembert, Halstedt, Herzog, Gambee, Allgöwer, Gussenbauer, Czerny, Wölfler, Albert, v. Mikulicz, etc.). Interrupted sutures offer the benefit in that the suture will not shorten and constrict the lumen when being tied.

    The benefit of continuous sutures is the time saved compared with material-intensive interrupted sutures and the adjustment in suture tension which follows luminal filling at the anastomosis. When the intestinal lumen is very full, this increases tension and in interrupted sutures will result in gaps between the sutures, while this tension is distributed evenly along the entire circumference of an anastomosis fashioned with continuous sutures. This will prevent  contaminated material from spilling into the surrounding tissue, thereby impeding abscess formation.

Single Access

Access to this lecture
for 3 days

€4.99 inclusive VAT

payment

webop-Account Single

full access to all lectures
price per month

for the modul: vascular surgery

from 8,17 €

hospitals & libraries

for the modul: vascular surgery

from 390,00 euros

  • General indication

    Paid content (text)
  • Special indication

    Paid content (text)
date of publication: 13.03.2012

Single Access

Access to this lecture
for 3 days

€4.99 inclusive VAT

payment

webop-Account Single

full access to all lectures
price per month

for the modul: vascular surgery

from 8,17 €

hospitals & libraries

for the modul: vascular surgery

from 390,00 euros

  • Selecting the intestinal loop

    107-1

    As an example, the suture is demonstrated in a right-sided hemicolectomy. An ileotransversostomy is planned. Owing to the long mesenteries, the intestine can be rotated here; therefore, the anterior wall will be sutured first, and after rotating the intestine this will be followed by the posterior wall.

  • Dissecting the intestinal wall

    107-2

    First, dissect free both intestinal walls at the planned anastomosis. Limit skeletonization of the intestinal wall to less than 1.5 cm for the small intestine and no more than 0.5-1 cm for the large bowel. Always check for a healthy, grayish-red color of the intestinal tissue, bleeding wound edges, and palpable or visible arterial pulses in the intestinal section to be sutured.

  • Resecting the intestine

    Paid content (video)
    Paid content (image)

    Block the intestine with intestinal clamps. By transecting the intestine with the scalpel perfusion of the intestinal wall will not be jeopardized.

    Note: The ileum is resected at an oblique angle to account for the bigger lumen of the transverse colon; if necessary, extend the ileum length of the anastomosis by slitting the ileum along its antimesenteric aspect.

  • Intestinal suture 1 (placing the stay sutures)

    Paid content (video)
    Paid content (image)

    Principle: Single-layer, extramucosal continuous full-thickness suture with two absorbable threads
    Material: Synthetic absorbable suture, monofilament or braided, size 3-0 or 4-0

    First, place one suture each on the mesenteric and antimesenteric aspect as an orientation and stay suture. This will half each intestinal lumen and assign it to its corresponding counterpart Tie the ends of the antimesenteric stay suture. One end of this tied stay suture in turn serves as another stay suture, while the anterior wall of the anastomosis is sutured with the other end.

  • Intestinal suture 2 (suturing the anterior wall)

    Paid content (video)
    Paid content (image)

    When placing the suture, take care not to include the mucosa (extramucosal suture), but stitch underneath it so the mucosa is turned inward (inverted) into the intestinal lumen. The assistant’s forceps can help with this process.
    After reaching the mesenteric aspect, tie the preplaced stay suture there. Then tie the shorter, non-needle-bearing end of the stay suture with the end from the first layer of the suture and then cut the latter. Now arm the shorter, non-needle-bearing end of the suture with a clamp and use it as a stay suture. In the next step, suture the posterior wall with the other end of the stay suture.

  • Intestinal suture 3 (suturing the posterior wall)

    Paid content (video)
    Paid content (image)

    The anterior wall has been sutured and the anastomosis extended between both stay sutures. Now rotate the intestine. Pull the stay suture located on the mesenteric aspect behind the intestine anteriad. Then suture the posterior wall with this suture using the same technique. After reaching the stay suture at the antimesenteric aspect, tie the ends of the sutures.

    Tip: For stability and to control bleeding ensure that the suture is under adequate tension. Too much tension will result in stenosis.

  • Intestinal suture 4 (checking the anastomosis)

    Paid content (video)
    Paid content (image)

    Now check the suture line and, if necessary, place additional stitches wherever direct serosa-serosa contact is lacking.
    Check the lumen of the anastomotic lumen between your index finger and thumb. And finally, check for leak tightness (by squeezing intestinal gas and fluid across the anastomosis).

  • Closing the mesenteric window

    Paid content (video)
    Paid content (image)

    To prevent internal hernia, close the mesenteric window with continuous 3-0 ® Vicryl sutures. As demonstrated in the video, this may proceed in centroperipheral direction or vice versa (see illustration).

    Note: Make sure that the perfusion of the anastomosis is not impaired, and no bleeding or hematoma has developed.

Single Access

Access to this lecture
for 3 days

€4.99 inclusive VAT

payment

webop-Account Single

full access to all lectures
price per month

for the modul: vascular surgery

from 8,17 €

hospitals & libraries

for the modul: vascular surgery

from 390,00 euros

  • Intra- and postoperative complications

    Paid content (text)

Single Access

Access to this lecture
for 3 days

€4.99 inclusive VAT

payment

webop-Account Single

full access to all lectures
price per month

for the modul: vascular surgery

from 8,17 €

hospitals & libraries

for the modul: vascular surgery

from 390,00 euros