Place the first suture at the Mesenteric border and the second at the Antimesenteric border.
INTESTINAL RESECTION AND ANASTOMOSIS
- End-to-end anastomosis is the gold standard.
- If the luminal diameter post-transection is anticipated to be unequal, use a perpendicular incision across the intestine with the larger luminal diameter and an oblique incision across the area with the smaller diameter.
- Make the oblique incision so the antimesenteric border is shorter than the mesenteric border.
- With equal luminal diameters, use a perpendicular incision.
- Intestinal healing is dependent upon blood supply, mucosal apposition and amount of surgical trauma
- Approximating sutures will facilitate the most rapid intestinal healing.
- Intestinal suture patterns need to include the tough submucosal layer, so be sure to incorporate it in your sutures. Omental wrap or pexy.
- Do not use catgut or multifilament suture materials when closing intestinal incisions.
MOST COMMON COMPLICATIONS AND DIFFICULTY
- Dehiscence and leakage are the most common severe complication. Use proper technique to avoid this complication.
- Tissue trauma/maceration from rough handling with traumatic forceps during suturing.
- Removal of more than 70% to 80% of the small intestine may result in short bowel syndrome.
- Gently reflect mesenteric fat from ends of bowel to identify bowel wall.
- Place stay sutures at the mesenteric and anti-mesenteric borders to begin the closure. This allows proper alignment and the best apposition and suture placement at the mesenteric border.
- Place atraumatic forceps (Doyens, assistant’s fingers, arms of Allis tissue forceps) at least one arcuate vessel away from the anastamosis site to prevent compromise to the blood supply at the anastamosis.
- The mesenteric border is most likely to leak. Begin your closure there and be sure that you incorporate the submucosa in your sutures.
- Consider using a serosal patch if delayed healing is expected.
When suturing the intestine it is important to eliminate eversion of the mucosa. Everted mucosa can be trimmed away with Metzenbaum scissors or by use of a modified Gambee suture pattern. You may close the anastomosis using simple interrupted sutures placed 2-3mm from the wound edge and 2-3mm apart or by using a simple continuous pattern with knots tied at the 6 and 12 o’clock positions, respectively.
INTESTINAL RESECTION AND ANASTOMOSIS:
SUTURE AND NEEDLE OPTIONS
|Brand||Needle Type||Needle Reference|
|Main Choice||Also Possible||Main Choice||Also Possible|
|Taper Point||RB-1, SH-1, SH, CT-2|
|LINEA ALBA||MONOCRYL* (young)
PDS* II (adult)
|VICRYL* PLUS||Taper Point
|SH-1, SH, CT-2, CT-1||RB-1, CT-3
FS-2, FS-1, FS, FSL, X-1, CP-2, CP-1
|Taper Point||RB-1, SH, CT-2, CT-1|
|Silk||Reverse Cut||FS-2, FS-1, FS||FSL, CP-2, CP-1, KS|
(20 lbs or less)
(20-45 lbs or less)
(50 to 75 lbs)
(75 lbs +)
|INTESTINAL WALL||4-0 or 3-0||4-0 or 3-0||3-0 or 2-0||2-0|
|LINEA ALBA||3-0||3-0 or 2-0 or 0||2-0 or 0||0 or 1|
|SUBCUTANEOUS||4-0||4-0 or 3-0||3-0 or 2-0||2-0|
|SKIN CLOSURE||4-0||4-0 or 3-0 or 2-0||3-0 or 2-0||2-0|