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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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A lesion was identified by chromoendoscopy with retroflexion and
insufflation under both white light and NBI illumination (Fig. 18-11A and
B).*
The lesion was ablated. Follow-up examination showed no residual lesion
(Fig. 18-11C).
Figure 18-12A and B illustrates the importance of obtaining both posterior
and anterior views of the anorectum by rotating the endoscope during
retroflexion.
FIGURE 18-12 A. No lesions are seen on posterior retroflexed view of the rectum
with NBI and acetic acid. B. Anterior retroflexed view of the rectum in the same patient
showing a large anterior lesion (arrows). C. Retroflexion view with the endoscope. Biopsy
showed LSIL. A, anterior; ARL, anorectal line; ATZ, anal transitional zone; L, left; LSIL,
low-grade squamous intraepithelial lesion; P, posterior; R, right; Scope, endoscope.
There are occasions where the lesions can be particularly difficult to find.
Chromoendoscopy was performed to detect anal SIL because of high-
grade SIL on anal cytology for the patient depicted in Figure 18-13.
FIGURE 18-13 A complex lesion seen in the anal pecten following treatment with
acetic acid and illumination with NBI through a self-lighted beveled anoscope. The
prominent surface vessels attest to the hypervascular character of the lesion. The lesions
were biopsied and ablated. Biopsy showed HSIL consistent with the anal cytology.
Asterisks indicate the areas of concern. HSIL, high-grade squamous intraepithelial lesion;
NBI, narrow-band imaging.
Three small high-grade lesions were found in between anal epithelial folds
and ablated.
*This is the same lesion as is shown by anal colposcopy in Figure 18-6A.
Postoperative Care
Resume normal diet
Resume normal activity
Follow-up on pathology
This will dictate the interval for the next procedure/surveillance.
Conclusions
Anal SILs are HPV-associated neoplasms that can progress to squamous
cell carcinoma. Lesion detection is necessary for diagnosis and
management.
Magnification, green filter/NBI, and treatment of the anoderm with acetic
acid and other chemical agents facilitate lesion identification.
Methods currently used for anal SIL detection include anal colposcopy
and ACE.
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PART III
The Abdomen
Chapter 19
Anastomotic Construction Techniques
MATTHEW F. KALADY
Perioperative Considerations
There are a variety of ways to construct safe and effective bowel
anastomoses.
No one particular anastomosis is considered “the best,” and the method
selected is often made based on surgeon preference, the clinical situation
at hand, and experience.
Surgeons should be aware of various anastomotic techniques, using
staplers or sutures.
It is imperative that surgeons use clinical judgment to decide which
anastomotic technique is most appropriate for each individual case based
on anatomy, quality of tissue, and patient- and disease-related factors.
The anastomotic technique may also rely on the availability of particular
instruments, instrument malfunction, and technical feasibility.
Clinical judgment, especially regarding when not to do an anastomosis, is
equally important as how do construct one.
Patients with severe malnutrition, immunosuppression, sepsis, shock, or
fecal contamination should be considered for a stoma without an
anastomosis.
General Technical Considerations
Use healthy tissues for anastomosis.
Ensure adequate blood supply to both ends of the bowel.
Mobilize both ends of the bowel to avoid tension.
Align corresponding mesentery without twisting or torsion.
TYPES OF ANASTOMOSES BASED ON ANATOMY
Enteroenteric or Ileocolonic Anastomoses
Perioperative Consideration/Approach
Enteroenteric anastomoses are commonly performed for small bowel
resection for Crohn disease (see Chapter 41), radiation enteritis, closure of
ileostomy (see Chapter 43 and 44), enterocutaneous fistulas (see Chapter
27), and resection of small bowel neoplasms.
Ileocolonic anastomoses are commonly used after ileocolic resection for
Crohn disease (see Chapter 41) or right colectomy for colon cancer (see
Chapter 22).
Equipment
Stapling devices (Fig. 19-1):
Linear cutting single-use reloadable stapler (linear cutting, 60 or 80 mm
length), 3.8-mm staple height
FIGURE 19-1 Different types of surgical staplers used in the construction of bowel
anastomoses. A. Linear cutting stapler. B. Transverse anastomosis (TA) linear
noncutting stapler. C. Laparoscopic articulating linear cutting stapler. D. PI linear
noncutting stapler. E. Circular end-to-end anastomosis (EEA) stapler.
Linear noncutting (60-mm length, 3.8- or 4.8-mm staple height)
End-to-end anastomosis (EEA) circular stapler (3.5-mm staples, 28, 31,
or 33 mm diameter)
Suture: Vicryl, polydioxanone (PDS), ethibond of various needle shape,
sizes, and thickness
Techniques
Side-to-side (functional end-to-end), stapled
Use wound protector to limit potential soilage of the wound edges.
Clear mesenteric borders and ligate mesentery.
Staple across bowel using a linear stapler at a healthy area of bowel.
Staple line should be parallel to the mesentery and go across the bowel
in the same plane from the mesenteric edge of the bowel to the
antimesenteric border.
Place the tips of the stapler on the antimesenteric side.
Angle the stapler away from the mesentery so that the antimesenteric
edge is slightly shorter than the mesenteric edge (Fig. 19-2A).
FIGURE 19-2 Stapled side-to-side anastomosis. An ileocolic anastomosis is
shown. A. Use a linear stapler to divide across the bowel. Note that the angle of the
stapler is toward the side of the bowel that will remain for the anastomosis so that
there is improved blood flow to the antimesenteric bowel wall. B. An enterotomy is
made on the antimesenteric corners of the staple line in the small bowel and a
corresponding colostomy in the colon. The openings are exposed with the use of Allis
clamps. C. The linear stapler is inserted into each limb of bowel, and the
antimesenteric bowel walls are aligned. D. Before closing and firing the stapler, the
surgeon’s hand is placed below the bowel and ensures that there is no mesentery or
other tissue included in the anastomosis and that the antimesenteric walls are
included. E. The common enterotomy is stapled across with a linear noncutting stapler.
Allis clamps are used to extend the open end of the bowel to ensure that the full
thickness of the bowel wall is incorporated in the stapler.
Open the antimesenteric corners of the staple line and anchor with Allis
clamps (Fig. 19-2B).
Place one arm of the stapler down each limb of the bowel (Fig. 19-2C).
Align the antimesenteric borders and close the stapler, place fingers
beneath the bowel and spread, pushing the mesentery laterally to ensure
that the antimesenteric borders are in the anastomosis (Fig. 19-2D), then
fire the stapler.
Close the common enterotomy (Fig. 19-2E) with a linear noncutting
stapler such as a transverse anastomosis (TA) stapler (Fig. 19-1), 3.8- or
4.8-mm staple height.
Ensure no bleeding from bowel staple lines.
Stagger the bowel staple lines when aligning to close enterotomy.
Ensure mucosa, submucosa, and serosa are all elevated and into the
stapler; check again after closing the stapler, before firing.
Resect the remaining edge distal to the staple line with a scalpel; there
will be some resistance as the scalpel cuts across the small bowel staple
lines.
Ensure hemostasis on the transverse staple line.
Imbricate the corners with 3-0 Vicryl sutures.
Reinforce the crotch of the anastomosis with 3-0 Vicryl suture.
Alternatively, oversew the full staple line with interrupted 3-0 Vicryl
sutures in Lembert manner.
Oversew the common enterotomy staple line with running 3-0 Vicryl
stitch.
Alternatively, enterotomy can be closed with suture or with another
linear cutting stapler.
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