Anastomotic technique, gastrointestinal, end-to-end, open, continuous, hand suture, rotation technique - general and visceral surgery

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date of publication: 13.03.2012

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  • Selecting the intestinal loop


    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


    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

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    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)

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    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)

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    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)

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    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)

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    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

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    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.