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Oval incision around the stoma with a skin margin of about 2 mm wide; dissect through the subcutaneous tissue and possibly close the stoma by suture (here, fixation of the proximal limb with a stay suture for better mobilization and to avoid wound contamination with fecal content of the small intestine).
Freeing and dissecting down to the fascia
Free the proximal and distal limbs along their circumference from their adhesions with the subcutaneous tissue down to the fascia while keeping close to the intestine. Here, the stoma is completely freed from the fascia while carefully sparing the small bowel mesentery. Dissect the skin and subcutaneous tissue only as much as appears necessary for safe intestinal suture. Excessive dissection increases the risk of hematoma and/or infection.
Freeing the small intestine
Dissecting the mesentery
Once the small intestine has been freed, skelettonize the mesentery of the proximal and distal limb only so far as to be able to resect the stoma section.
Comment: Some surgeons dissect the scar remaining on the intestinal wall to allow direct anastomosis. For this resect the remaining skin with scissors. Take care that the posterior wall of the intestine is spared as wide as possible. After checking that the mesentery is intact, close the intestine with an absorbable monofilament continuous submucous suture 4/0.
If the bridge of the posterior wall is too small, if vascular injury to the mesentery has impaired intestinal circulation or if the intestinal segment to be anastomosed demonstrates ischemia, a short resection of the intestinal segment with direct anastomosis is mandatory.
Since the bridge of the posterior wall is too small in the majority of cases, short resection with direct anastomosis should be regarded as standard procedure. This can be end-to-end or, as in this article, side-to-side.
Resect the stoma-bearing ileum segment (length: approx. 10cm). This can be done sharply (after placing soft intestinal clamps) when constructing an end-to-end anastomosis or, as here, with a stapler. This is the more expensive variant, which, apart from a small gain in time, offers no significant benefit. The decisive factor is a sufficiently wide anastomosis to avoid postoperative motility disorders and the danger of ileus.
Preparing the anastomosis
When constructing a side-to-side anastomosis grasp the ends of the intestinal limbs, place them parallel to each other (isoperistaltic) for a distance of approx. 10cm .
End-to-end anastomosis is also possible or rather the standard. This has no disadvantages compared to side-by-side anastomosis. Which variant is preferred depends on the standards of the respective department.
Opening the limbs of the small intestine
Construct a single-layer tension-free isoperistaltic side-to-side anastomosis with a continuous suture, preferably delayed absorption monofilament 3/0 or 4/0.
Construct the posterior wall with a full thickness suture while taking seromuscular bites on the anterior wall.
The anastomosis is absolutely tension-free, widely patent on palpation and demonstrates good supply.
Start with the posterior wall. Some surgeons prefer separate sutures for the posterior and anterior wall.
Many others construct an end-to-end anastomosis.
Close the mesentery
Delivering the bowel back into the abdominal cavity
Closing the peritoneum and posterior lamina of rectus sheath
Closing the anterior lamina of the rectus sheath
Closing the wound