Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
.pdf
The author prefers to use an omental pedicle flap (Fig. 19-3A and B)
around an ileocolic anastomosis.
FIGURE 19-3 Omental pedicle flap over the anastomosis. A. The omentum is
partially freed and mobilized from the remaining transverse colon to create a floppy
omental flap. B. The omental flap is loosely secured to the bowel or mesentery with 30 Vicryl sutures.
Side-to-side (functional end-to-end), sutured
As earlier, the proximal and distal margins of the bowel are stapled
across and divided.
Alternatively, they can be sewn closed.
Antimesenteric borders are aligned and stay sutures placed to align the
two segments of the bowel (Fig. 19-4A).
FIGURE 19-4 Sutured side-to-side anastomosis. An ileocolic anastomosis is
shown. A. The antimesenteric bowel walls are aligned, and stay sutures are placed to
help with alignment and retraction. A posterior wall running suture is then placed as
the deep layer of the anastomosis. B. Longitudinal enterotomy and colostomy is made
in each limb of bowel, respectively. C. The inner layer of the posterior wall is
completed with running full-thickness sutures. D. Detailed view of the transition of the
corner stitches and Connell stitch on the anterior wall inner layer of the anastomosis.
E. Completion of the outer layer of the anterior wall with Lembert sutures.
Posterior layer of a running 3-0 PDS suture through the seromuscular
layers is placed to appose the two limbs of bowel (Fig. 19-4A).
Longitudinal enterotomies are made (Fig. 19-4B).
The posterior walls of the bowel are sutured together with a fullthickness 3-0 PDS running stitch, focusing on incorporation of the
submucosal layer. There are two initial sutures placed in the middle of
the backwall and then run to opposite ends of the anastomosis (Fig. 194C).
The suture transitions to a Connell suture at the corners and along the
anterior wall (Fig. 19-4D).
The anterior second layer of the anastomosis is completed with
interrupted 3-0 PDS Lembert, imbricating the stitches (Fig. 19-4E).
This layer can also be done as a running suture if preferred.
The author prefers PDS suture for running anastomosis for its ease of
passage through the tissue.
End-to-side anastomosis, stapled
Divide both ends of the bowel between clamps sharply.
Open bowel lumens and ensure adequate health and blood supply.
Assess for size of stapler that will be accommodated by small bowel
lumen.
Secure anvil into the open end of the small bowel using a “0” Prolene
purse-string suture (Fig. 19-5A).
FIGURE 19-5 Stapled end-to-end anastomosis. An ileocolic anastomosis is
shown. A. The anvil is secured in place with a running “0” Prolene suture. The closed
bowel wall should not have any gaps on the anvil. B. The stapler is introduced through
the open end of the colon, and the spike is brought out on the antimesenteric wall,
about 5 cm from the open edge. C. The spike is mated with the anvil and D. closed to
appose the two ends of bowel, ensuring that no other tissues are involved and that the
mesentery is appropriately aligned. E. The open end of colon is then stapled across
with a linear noncutting stapler.
Use full thickness but small bites of bowel so that the entire bowel wall
gets brought into the anvil, but there is no bunching of tissue.
Prepare the bowel so that peritoneum and fat are not in the anastomosis.
The entirety of the fat does not need to be removed, rather, just the
peritoneal or outer lining so that the fat is essentially pushed out of the
stapler when it is closed.
Avoid pulling the mesentery into the circular stapler.
Open the end of the colon and introduce the stapler with the penetrating
spike to exit through the antimesenteric area of the colon,
approximately 5 cm from the open edge or where the final resection
line will be (Fig. 19-5B).
Couple the anvil and the spike (Fig. 19-5C) and close the providing
gentle traction on the small bowel so that the stapler closes smoothly
and securely (Fig. 19-5D).
Fire and remove the stapler, check the anastomotic rings for
completeness.
Pass a Kelly clamp through the open end of the colon and ensure that
both the proximal and distal lumens are completely patent.
Staple across the open end of the colon, allowing approximately 5 cm
between the anastomosis and the linear staple line to ensure good blood
flow and no blocking in a short segment (Fig. 19-5D).
Oversew the linear staple line with 3-0 Vicryl, imbricating the ends.
Oversew the circular staple line with interrupted 3-0 Vicryl stitches.
End-to-side anastomosis, sutured
Divide small bowel between bowel clamps sharply. Divide the colon
with a linear cutting stapler.
Open small bowel lumen and ensure adequate health and blood supply.
Perform a colotomy on the antimesenteric border, approximately 5 cm
distal to the staple line for the end-to-side sutured anastomosis (Fig. 196A).
FIGURE 19-6 Sutured end-to-side anastomosis. An ileocolic anastomosis is
shown. A. After the colon is closed and divided with a linear stapler and the bowel has
been sharply resected leaving an open end, a colotomy is made in the antimesenteric
colon wall to a size to match the small bowel lumen. B. Stay sutures are placed to help
with alignment and retraction. The posterior wall of the anastomosis is completed with
interrupted full-thickness sutures. C. The sides and anterior wall are completed with
full-thickness interrupted sutures.
Use full-thickness sutures through the backwall of the colotomy and
small bowel (Fig. 19-6B).
Complete the front wall of the anastomosis with full-thickness 3-0
Vicryl suture (Fig. 19-6C). An additional imbricating suture layer
anteriorly may be considered.
End-to-end, sutured
This technique is preferred for anastomosis dilated bowel, thickened
bowel wall, or if there is a size mismatch between bowel lumens.
Divide bowel at each resection point sharply between noncrushing
bowel clamps.
Place stay sutures in two areas of the bowel, 1800 apart on the
circumference, to avoid excessive handling the bowel lumen (Fig. 197A).
FIGURE 19-7 Sutured end-to-end anastomosis. An ileocolic anastomosis is
shown. A. Stay sutures are placed to minimize handling of the bowel. B. The posterior
wall of the anastomosis is constructed using interrupted Turnbull sutures. C. If there is
size mismatch between the bowel lumens, a Cheatle slit may be performed on the
smaller lumen. D. The anterior wall is reinforced with imbricating sutures.
Place backwall sutures, as Turnbull sutures that incorporate full
thickness of the bowel wall and then vertical mattress back through the
mucosa, inverting the mucosa (Fig. 19-7B).
If there is a size discrepancy, dilated bowel, or thickened bowel wall, a
Cheatle slit may be employed to enlarge the lumen for anastomosis
(Fig. 19-7C).
Transition at the corners to seromuscular sutures, inverting the mucosa.
Place 3-0 ethibond imbricating sutures over the anterior layer (Fig. 197D).
PEARLS AND PITFALLS
Submucosa is the strongest area of the bowel wall and is the cornerstone
of any handsewn anastomosis. Ensure that sutures incorporate this
layer.
Test for adequate blood supply by unclamping the artery before ligating
it. Also, there should be vigorous bleeding in the cut edges of the bowel.
Always ensure there is enough mobility to the ends of the bowel that are
being connected so that there is no tension or torsion on the
anastomosis.
Avoid or limit “dog ears” on the anastomosis. This can be done by
incorporating one of the dog ears into the staple line. If dog ears are
present on the corner, use suture to imbricate them.
Hematomas can cause separation of the anastomotic suture line or
compromise the arterial and/or venous blood flow. Always confirm
hemostasis of the completed anastomosis. When creating a stapled sideto-side anastomosis, the lines should be inspected before closing the
common enterotomy.
Ensure that there is adequate distance between the stapled across end of
the colon and the end-to-side anastomosis so that there is not a short
watershed area with decreased blood flow, which can cause ischemia.
ILEORECTAL AND COLORECTAL ANASTOMOSES
Perioperative Considerations
Ileorectal anastomosis is commonly used after a total colectomy for Crohn
disease, familial adenomatous polyposis, constipation, or for colon cancer
in the setting of a hereditary syndrome.
Colorectal anastomosis is commonly used after a sigmoid colectomy or
left colectomy for diverticulitis or cancer.
Equipment
Stapling devices (Fig. 19-1)
Laparoscopic: Medtronic Endo GIA purple load tristaple technology,
45 or 60 mm long
Medtronic DST Series GIA single-use reloadable stapler (linear,
cutting, 60 or 80 mm length), 3.8- or 4.8-mm staple height
Medtronic DST Series TA titanium staples (linear, noncutting, 60 mm
length), 3.8- or 4.8-mm staple height
DST Series EEA circular stapler; 3.5-mm staples, 28, 31, and 33 mm
diameter
Suture: Vicryl (polyglactin), PDS, ethibond
Techniques
End-to-end, stapled
The rectum is cleared of surrounding mesorectum to the bowel wall and
then stapled across.
If done laparoscopically, an articulating linear cutting stapler is
preferred. Usually, the mesenteric fat can be cleared sufficiently so
that a single firing of the stapler can be used.
A laparoscopic view of a stapled across rectal stump is shown in
Figure 19-8A.
FIGURE 19-8 Stapled end-to-end anastomosis (EEA). A colorectal
anastomosis is shown. A. Laparoscopic view of a stapled across end of the rectum.
B. The exteriorized colon is held open with Babcock clamps, and a purse-string
suture is placed to secure the anvil of the EEA stapler. C. Laparoscopic view of
Соседние файлы в папке Библиотека им академика М.И. Перельмана