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stapler spike brought out through the transverse staple line on the rectal stump. D.
Laparoscopic view of the colon and rectum joined via closure of the EEA stapler. E.
Schematic of joining the stapler. F. Endoscopic view of the completed anastomosis
demonstrating patency and hemostasis.
During a laparoscopic technique, the proximal portion of the bowel is
exteriorized after distal resection. The ileum or colon is divided sharply
between bowel clamps.
Open the proximal bowel lumen and ensure adequate health and blood
supply.
For a colorectal anastomosis, the marginal artery is cut sharply
before being completely clamped and tied to evaluate the degree of
blood flow.
Adequate mobilization is performed to avoid tension on the
anastomosis. This usually requires mobilization of the splenic flexure
with a colorectal anastomosis.
Secure an appropriately sized anvil into the open end of the
proximal bowel using a “0” Prolene suture.
When performing the purse-string suture, use full thickness but small
bites of bowel so that the entire bowel wall gets brought into the anvil.
Ensure there is no bunching of tissue.
The author’s preference is to use a 33-mm EEA stapler, but a 31 mm is
more commonly used due to the bowel lumen size. To help place the
anvil into the lumen, Babcock clamps are placed on opposite ends of
the bowel lumen to provide traction (Fig. 19-8B).
Once the anvil is in the lumen, tie the purse-string suture so that it
bowel wall pulls in snug on the anvil. Avoid pulling the mesentery into
the circular stapler.
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.
Insert the EEA stapler into the anus and advance it to the top of the
rectal stump, avoiding injury to the rectal mucosa, and also avoiding
penetration of the top of the rectal stump staple line.
Alternatively, a sigmoidoscopy in air can be used.
If these do not work, also look for a peritoneal band at the reflection
that may be preventing passage of the stapler to the apex.
Finally, ensure there is not retained sigmoid that may have to be
resected.
Once the stapler is at the top of the rectal stump, the spike is advanced
through the tissue at the transverse staple line. Efforts are made to bring
the spike out slightly asymmetrically so that one of the corners of the
transvers staple line is incorporated into the circular anastomosis.
A laparoscopic view is shown in Figure 19-8C.
This maneuver avoids have two small “dog ear” corners with short
distance to the circular staple line, which may be prone to leak.
Alternatively, a purse string can bring the corners in to be
incorporated into the stapled anastomosis.
The anvil is coupled onto the spike and the stapler is closed, ensuring
that other structures such as ovaries, ureters, and fallopian tubes are
away from the anastomosis (Fig. 19-8D). A schematic of this step is
shown in Figure 19-8E.
The appropriate orientation of the mesentery is checked again so that
there is no tension or torsion.
Only after the two safety check points above are satisfied, should the
stapler be fired and removed.
The anastomotic donuts are check for completeness.
If there is a corner “dog ear,” it is imbricated with a 3-0 Vicryl stitch.
Evaluation of the anastomosis is performed. The pelvis is filled with
saline or sterile water (for cancer cases), and the bowel proximal to the
anastomosis is gently occluded.
A flexible sigmoidoscope is inserted through the anus and advanced
to the level of the anastomosis, with insufflation of air.
From the abdominal exposure, the surgeon ensures there are no
bubbles seen from the submerged anastomosis. On the endoscopy
side, an observation can be made regarding the patency and
hemostasis of the anastomosis (Fig. 19-8F).
End-to-end, sutured
In preparation for a sutured EEA, the rectum is divided sharply after
occlusion with a bowel clamp.
The proximal bowel for the anastomosis is prepared as above.
Size discrepancy should be evaluated and lumens prepared for
reasonable size match.
A Cheatle slit may be needed to enlarge the lumen of the small bowel
for an ileorectal anastomosis.
It is the author’s preference to perform a side-to-end if there is a size
mismatch significant enough to require a Cheatle slit in the small
bowel.
A colorectal anastomosis usually presents a reasonable size match.
The anastomosis is done with interrupted 3-0 Vicryl sutures. The
backwall is completed first using interrupted Turnbull stitches that
incorporate full-thickness in-to-in and passage back through just the
submucosa and mucosa in-to-in with tying on the same side of the
lumen to evert the mucosa. After the backwall is completed, the corner
stitches transition to seromuscular only with inversion of the mucosa.
The anterior wall is completed with interrupted seromuscular stitches.
The anterior wall is reinforced with a second layer of interrupted 3-0
imbricating sutures. This technique is similar to that as illustrated in
Figure 19-7.
A leak test and anastomotic evaluation is done as described earlier.
Side-to-end, stapled
The proximal and distal bowel are stapled across with linear cutting
staplers.
An enterotomy or colotomy is made on the antimesenteric border of the
proximal bowel, approximately 5 cm proximal to where the final staple
line closure will be. This can be done via the sharp spike introducer
(Fig. 19-9A), which is then removed.
FIGURE 19-9 Stapled side-to-end anastomosis. A. The stapler is introduced
through the open end of the colon, and spike is brought out. B. The open end of the
colon is stapled across and closed, ensuring that at least 5 cm of the colon remains
between the end of the colon and the circular anastomosis to avoid potential ischemia.
C. The colon with the transverse staple line oversewn and the anvil exposed in
preparation to return to the abdominal cavity and completion of the colorectal
anastomosis. D. Drawing of the orientation of a completed side-to-end colorectal
anastomosis.
The open end of the colon or small bowel is then stapled across with a
TA60 green–loaded stapler (Fig. 19-9B).
The author prefers to oversew the transverse staple line with 3-0 Vicryl
running suture to promote hemostasis and decrease leak (Fig. 19-9C).
The EEA stapler is then inserted into the anus and advanced to the top
of the rectal stump, avoiding injury to the rectal mucosa, and also
avoiding penetration of the top of the rectal stump staple line (as shown
in Fig. 19-8C). Rounded EEA sizers may be utilized to gently dilate the
rectum along its entire length to allow accommodation for the stapler.
The anastomosis is then completed as described for the stapled EEA, as
described earlier. A leak test is performed. A drawing of the completed
side-to-end stapled anastomosis is shown in Figure 19-9D.
Side-to-end, sutured
The proximal bowel is divided with a linear cutting stapler. The distal
bowel (the rectum) is divided sharply with a bowel clamp distal.
An area is chosen in the proximal bowel approximately 5 cm proximal
to the staple line, and an enterotomy (or colotomy) is made on the
antimesenteric border (Fig. 19-10A). The length of the bowel opening
should be commensurate with the lumen of the distal bowel for the
anastomosis.
FIGURE 19-10 Sutured side-to-end anastomosis. An ileorectal anastomosis is
shown. A. The antimesenteric border of the small bowel is aligned with the open end
of the rectum, and an appropriately sized enterotomy is made to match the rectal
lumen. B. The posterior wall of the anastomosis is completed with interrupted Turnbull
sutures. C. After completion of the inner layer of the anterior wall of the anastomosis,
an outer layer is completed by placing interrupted imbricating sutures.
The anastomosis is performed with interrupted 3-0 Vicryl sutures. The
backwall is completed first using interrupted Turnbull stitches that
incorporate full thickness in-to-in and passage back through just the
submucosa and mucosa in-to-in with tying on the same side of the
lumen to evert the mucosa (Fig. 19-10B). After the backwall is
completed, the corner stitches transition to seromuscular only with
inversion of the mucosa.
The anterior wall is completed with interrupted seromuscular stitches.
The anterior wall is reinforced with a second layer of interrupted 3-0
imbricating sutures (Fig. 19-10C).
A leak test and anastomotic evaluation is done as described earlier.
TIPS
Rounded EEA sizers may be utilized to gently dilate the rectum along
its entire length to allow accommodation for the stapler.
PEARLS AND PITFALLS
For handsewn anastomoses, use a monofilament as it glides nicely
through the tissue.
Ensure there is no tension on the anastomosis.
It may be difficult to mobilize the proximal colon for a colorectal
anastomosis.
Maneuvers to release tension and provide adequate length for the
anastomosis include performing a high ligation of the inferior
mesenteric vein at the inferior border of the pancreas, mobilization of
the splenic flexure, and separation of the omentum from the colon.
For colorectal anastomoses, always assess appropriate blood supply by
unclamping the marginal artery on the colon side to check for pulsatile
bleeding. Nuisance bleeding in the submucosa is another sign of
adequate blood supply. This can be noted when dividing the bowel
sharply.
Always perform an anastomotic leak test.
If there is a small anastomotic defect noted on leak test, the defect can
be repaired with suture and rechecked.
Suggested Reading
Steele SR, Hull T, Read TE, Saclarides T, Senagore A, Whitlow C, eds. The ASCRS Textbook of Colon
and Rectal Surgery. 3rd ed. New York, NY: Springer Publishing; 2016.
Chapter 20
Complicated Anastomoses: TurnbullCutait
SHERIEF SHAWKI
Perioperative Considerations
The Turnbull-Cutait technique is typically used in setting of reoperative
pelvic surgery or when dealing with large recto-urethral fistulas secondary
to radiation for prostate cancer.
Reoperative surgery is one of the most complex facets of colorectal
surgery, in which success relies mainly on planning and an optimal
decision-making process.
Preoperative Assessment and Evaluation
Review prior clinical events and any health-related medical and/or
surgical episodes.
Review of operative notes, pathology slides, and imaging are of utmost
importance. One should understand the patient’s current anatomy, prior
postoperative complications, and duration of problems—the latter can
reflect the potential hostility of the intra-abdominal and pelvic cavity.
Evaluate functional and nutritional status and candidacy for successfully
undergoing a major surgery.
Evaluate functional status of the anal sphincter mechanism.
Discussion with the Patient
Is it worth it? It is crucial to discuss with patients the risks and benefits, as
well as the potential complications prior to any reoperative pelvic surgery.
Set realistic expectations.
Discuss expected bowel function as this will be altered from the past.
Ensure the timing of the procedures allows for optimizing success.
When the indication for such procedure is leak and infection, proper
sepsis control is a key.
Do not allow for a long-standing pelvic infection to commence, if
possible, to avoid frozen pelvis and fibrosis of surrounding pelvic
tissues.
This will render the surgical procedure more difficult and may not
provide space for the new colonic conduit to fit in the pelvic cavity
nor reach through the pelvic floor.
Review all radiographic and endoscopic anatomy. Ask yourself:
How much colon is left?
Has there been a prior mobilization of splenic flexure?
Was the inferior mesenteric artery (IMA) and or left colic vessels
divided?
What is the status of the inferior mesenteric vein (IMV)—has it been
divided already?
All of these questions will give an estimation for potential problems with
achieving the length needed to perform a pull-through procedure.
Operative Planning
Prepare for a long case; these often will take several hours.
Obtain an appropriate level of assistance across the entire operating room
team.
Assure you have the capability of rapid resuscitation.
Type and cross the patient for the potential need for blood transfusion.
Positioning
Modified lithotomy Lloyd-Davis position
Bilateral ureteric stents (in case of reoperative abdominopelvic surgery)
Skin preparation for both the abdomen and the perineum to include a
vaginal preparation, as indicated.
All extremities should be properly positioned and padded.
The patient perineum should be placed on the edge of the operative table,
with a blanket roll underneath the sacrum to facilitate accessibility during
perineal phase.
Special Equipment
Standard laparotomy set
Mechanical staplers, if required
Long instruments
Deep pelvic retractors, lighted preferred
Vaseline gauze and cotton gauze to wrap the exteriorized colon and
retained full sutures to be used in future delayed anastomosis
#1 Vicryl sutures or Lone Star (Cooper Medical) device for anal eversion.
Technique
Stage I
Abdominal phase: preparing the conduit. (Note: Only the main steps are
mentioned here, as the primary chapter focuses on the perineal phase of
the Turnbull-Cutait.)
Identify anatomy and perform a proper and safe adhesiolysis.
Perform a complete splenic flexure mobilization.
If needed, to gain maximum length: ligate the IMA, left colic artery,
and IMV below the inferior border of the pancreas.
Entering the pelvis:
Identify both the ureters.
Enter the pelvis in the correct plane and avoid entering in the
presacral plane.
Be ready to deal with presacral bleeding, however, try to avoid it if
possible.
Electrocautery
Thumbtacks
Bone wax
Suture ligation
Muscle weld
Packing
Keep the great vessels away from harm.
Dissection should continue to the pelvic floor/levator muscle.
Transect the bowel—to include the prior anastomosis—as distally
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