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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_725_Библиотеки_им_академика_М_И_Перельмана
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We maintain that the one-layer, continuous method, using a
monofilamentsuturematerial,istheonethata‘modernsurgeon’should
adopt, because it is fast, cheap and safe. What is good for the highpressure vascular anastomosis should be just as good for the lowpressureintestinalone.Ifthefirstlayersufficeswhynarrowandinjureit
with inverted and strangulated tissue? Would you put a well-done
hamburgerbackonthegrill?Aswithanybeautifulpieceofart,lessis
more.
We acknowledge that staplers areelegant, admired by theoperating
roomstaff,‘fun’touseandofgreatfinancialbenefittothemanufacturers.
Certainly, staples may be advantageous in selected areas,deep in the
pelvis or high under the diaphragm, for rectal or esophageal
anastomoses, respectively. But those types of anastomoses are
seldom performed in emergency situations. Furthermore, as a
surgicaltraineeyoushouldstartusingstaplersonlyafterachieving
maximal proficiency in manual techniques, and in difficult
circumstances.Eventhestapleraficionadohastousehishandswhen
theinstrumentmisfires,orcannotbeusedbecauseofspecificanatomic
constraintssuchastheretroperitonealduodenum.
There are stapler tricks even for that… just use the EEA™ stapler, place the anvil in the
duodenumusinga purse-string,andconstructanend-to-sideanastomosistothesmallbowel.
Notthatdifferentfromanesophagojejunostomy.Danny
Themodernsurgeon,andthetraineetoo,needtobeequallyproficient
in both hand-sewn and stapled anastomotic techniques; we suggest,
however,thatbeforedrivingatruckyoushouldbeabletomanageacar.
Thereissomeevidence(notlevelI)that,intraumapatients,stapled
intestinal anastomoses are more prone to leak than hand-sewn
ones. This has been attributed to the post-resuscitation bowel edema
which develops after severe injury (the staplers cannot ‘adjust’ to the
swelling of the bowel — the surgeon’s hands can). It is also our
impression that a continuous, monolayer anastomosis occasionally fails
when performed in edematous bowel (e.g. after massive fluid
resuscitationorsevereperitonitis).Fromfindingsatreoperationwehave
learned that subsequently, as the bowel edema subsides, the suture
becomes loose, leading to anastomotic dehiscence. The same
arguments may apply when resection for obstruction has been
performed;theproximaldilated,thickenedboweldoesnotconformtothe
staplesinthesamewaythatthedistalgutdoes.
Therefore, when anastomosing swollen, edematous bowel we
prefer not to use staplers or the continuous hand-sutured
method. Instead, we use a closely placed single layer of
interrupted sutures — individually tied “not too tight, not too
loose”— in ordertoavoid cutting throughthe bowel edges,but
alsotoobviatetheriskoflooseningaftertheedemasubsides.
A similar interrupted technique may be preferred in colo-colo
anastomoses where the avoidance of the hemostatic effects of
continuous sutures may have theoretical advantages. Furthermore, in
thissituation, the abilityof the colontochange dramatically indiameter
under normal physiological conditions may be impaired if a continuous
suturewith its fixed lengthisutilized. We admit,however,that scientific
datatobackthesehypothesesarelacking.
And remember: when the bowel edges are not ‘perfect’ take deeper bites!
Incorporatemoretissue intotheanastomosis!Yes—uptoacm!When assisting
ayoungersurgeonweconstantlyhearourselvespleading:takea
largerbite!
Howwedoit
Our preferred continuous, monolayered anastomosis uses one
double-armed,ortworegular,3-0or4-0monofilamentsutures(PDS®or
Maxon™).Nobowelclampsareused,asweliketoassesstheadequacy
ofbloodsupplytotheboweledges.Itisnotnecessarytodevascularize
the bowel edges by ‘cleaning off’ the fat at the mesenteric side or
removing appendices epiploicae. The suture line begins at the
posterior/mesentericwall, running ‘overandover’towardsbothsides to
meet,andbetied,anteriorly(attheanti-mesentericborder).Thesecretis
totakegenerousbites throughthe submucosa,muscularis andserosa
and avoid the mucosa (“big bites outside, small bites inside”), thus
invertingit.Thissuturingtechniqueisknownvariouslyasextra-mucosal
orsero-submucosal.Theneedleexitorentrysiteontheserosalsideis57mm from the bowel edge (we repeat:even 1cmor morewhen the
bowelisthinoredematous—toobigbitescan’tharmbuttoosmall
canleak),whilethedistancebetweenthebitesshouldbesuchasnotto
allow access to the tips of a Debakey forceps (3-4mm). The assistant
who ‘follows’ the suture should use just enough tension to maintain
approximationandavoidstrangulationofthetissue(areliableassistant
is crucial!) In addition to the end-to-end situation, this technique suits
alsoboththe end-to-side and side-to-side versions andinessenceit is
theintestinal version ofaroutine vascular anastomosis,except that the
vascular one is everted. Essentially, you create an inverted and safe
anastomosis,withawidelumen,usingonlyasutureortwo,inlessthan
15minutes.
In ‘difficult’ situations, when the anastomotic site is relatively
inaccessible, or the bowel edematous, we prefer a one-layer
interrupted technique, which allows more accurate placement of
sutures and the theoretical advantages mentioned above. For this
purposeweuseVicryl®sutures, 3-0or 4-0,which areeasiertotiethan
monofilament. Again, we start with the posterior wall and progress,
alternately, on each side to meet at the front. As with the continuous
method,wetakebigbitesontheoutsideandtinyontheinside,inverting
themucosa. All sutures,exceptthe last few atthe front, are tiedinside
thelumen.
Nowraiseyourrighthandandrepeat:BIGBITES,BIGBITES,BIGBITES,BIGB…
Afewmorewordsonstaplers
You will learn the correctuse ofstaplers from your mentors. Despite
appearances, we are not rigidly ‘staplerophobic’. We use staplers
generouslyinemergencysituationstoocclude,ratherthananastomose;
a classic example would be closure of the rectum after a Hartmann’s
procedure or small bowel transection in an abbreviated laparotomy for
trauma or ischemia. Doing a functional end-to-end small bowel or
ileocolicanastomosisaftersmallbowelresectionorrighthemicolectomy,
respectively — using a linear cutting (GIA™) and linear occluding (TA)
staplersmakessense tous.But aside-to-sidegastrojejunostomy,when
youinserttheGIA™intothestomachandsmallbowelthroughtwoholes,
which you then have to close with sutures, makes no sense, as the
combinedsizeofthegastricandjejunalenterotomiesisalmostthatofthe
gastrojejunostomy which you could havecreated andsutured byhand.
Moreover, theseenterotomies which are used to insert the jaws of the
linear cutting staplers, and are then closed by hand, seem to be the
Achilles’heeloftheanastomosis—they,ratherthanthestapleline,are
oftenthesiteofaleak.
Asistrueforanythinginsurgery—it’sthefinaloutcomethatmatters.Andwhatdeterminesthe
outcomeof an anastomosisaremainly the conditionsof the bowel, thesurroundings and the
patient.Thetechnicalvarianthaslittleeffectaslongasitisdoneinanaccurateandmeticulous
way. So for me, all these calculations about sizeof enterotomies oroverall time fromstart to
finishofananastomosisaremeaningless.Ihaveseen laparoscopic hand-sewn anastomoses
donequickerthanopenstapledones…AndIhaveseenplaceswherethecostof15minutesof
ORtimeisgreaterthanthecostofthestaplers…Sothechoiceismultifactorial,basedoncost,
speed, and mainly personal preferences. As long as your leak rate is not
exceptional,andyouareproficientinallthe variations—youare
freetochoose.Danny
Testingtheanastomosis
Acorrectlyperformedanastomosis—thatis,ifitisindicated—
shouldnotleak.Thereislittlepointinroutinelytestingyoursimpleintra-
abdominal intestinal anastomosis; the common practice of pinchingmasturbatingtheanastomosistoconfirmanadequatelumenislaughable
if you used a one-layer technique as described above. ‘Problematic’
anastomoses, such as those performedin the lower rectum, shouldbe
tested:simplyclampthebowelabovetheanastomosis,fillthepelviswith
salineand injectair intothe rectum.Instead ofairyou maywish touse
dye.Ifair bubbles(or dye) are observed leaking,an attempttoidentify
andcorrectthedefectisindicated;ifunsuccessfulordoubtful,aproximal
diverting stoma is necessary. We (some of us anyway) also test the
closureofaperforatedduodenalulcerbyinjectingdyeintothestomach.
Whennottoperformananastomosis?
We wish we had an exact answer! In broad terms, whenever the
probabilityofaleakishigh,avoidananastomosissinceanyanastomotic
leakportendsdisastrousconsequences( Chapter47).Sohowdoyou
accuratelypredictanastomoticfailure?
Traditionally, the avoidance of colonic suture lines during emergency
operations for trauma, obstruction, or perforation was the standard
practice.Buttimeshavechanged;duringWorldWarIIacolostomywas
mandatory for any colonic injury, but nowadays we successfully repair
mostofthesewounds( Chapter32).Furthermore, three-ortwo-stage
proceduresforcolonicobstructionhavebeenreplacedinselectedcases
by the one-stage resection with anastomosis ( Chapter 27). And, as
you will read in Chapters 27 and28, the issue of whether the large
bowel is ‘prepared’or not hasbecome a non-issue (at leastto most of
us). Multiple prospective randomized trials show that safe colorectal
suturelinescanbeeffectedinunpreparedbowel.
It is difficult to lay down precise guidelines as to when an
intestinalanastomosisisnottobemade.Youshouldmakeacareful
decisionafterconsideringtheconditionofthepatient,theintestine,
and the peritoneal cavity. Generally, we would avoid a colonic
anastomosisinthepresenceofestablishedanddiffuseintra-abdominal
infection(asopposedtocontamination)andundertheconditionslistedin
Table 14.1. Regarding the small bowel, anastomosis is indicated in
mostinstances;however,whenmorethanoneofthefactorslistedinthe
tablearepresentwetendtoerrontheconservativesideandexteriorize
ordivert,dependingontechnicalcircumstances.
Noformulaoralgorithmisavailable,souseyourjudgmentandtrynot
to be too obsessive in always attempting an anastomosis — look at
Figure14.2—isthisyourboss?Yes,weknowthatyouwishthepatient
wellbywantingtosparehimastoma,buthewillnotbeimpressedifheis
dead! You should not be fearful of creating a high small bowel stoma.
Previously these were considered to be unmanageable, but with total
parenteral nutrition, techniques of distal enteric feeding and re-infusion,
somatostatin,andstomacare,thesetemporaryproximalintestinal‘vents’
canbelife-saving(seealso Chapters47and48).Ontheotherhand,
do not be a wussy (look at the Urban Dictionary) by avoiding an
anastomosiswhenitisindicatedandpossible.
Figure 14.2. Anesthetist: “Systolic blood pressure 60… hemoglobin 5…” Assistant to
surgeon:“Boss,pre-opalbuminwas1.5…”Surgeontonurse:“GetmetheTAandGIA™.
Letmejointheileumwiththecolon.Willtakeme3minutes…”
Whatever you do, some people will be unhappy. You can’t please
everybody,canyou?Ifyoudoacolostomytherewillbealwayssomeonetoaskyouwhy
not primary anastomosis? If you do a primary anastomosis there will be always
someonetosaywhynotcolostomy?Onlybeingafootballcoachisworseinthisregard.
Soletusleaveyouwiththis...
The intestinal anastomosis is the ‘elective’ part of the emergency
operationyouaregoingtoperform.Remember—youraimistosavelife
and minimize morbidity; create an anastomosis when its chances of
success are at leastreasonable. Thereare manywaysto skin acat
andtofashionananastomosis.Masterafewmethodsandusethem
selectively.
2
Intestinalstomata
2
MarkCheetham
Throughout surgical history surgeons have viewed the creationof an
intestinal stoma with distaste but, at the same time understood its
potential life-saving value — as reflected by these two quotes from
mastersurgeons:
Ofallthediseasestowhichmanisliable,thereisnooneso
inconvenient and disgusting as the artificial anus. How
wretched is the patient from whom, despite his will, the
alimentary, bilious and fecal matter contained in his
intestinesareconstantlyescaping.
GuillaumeDupuytren
Aboutcolostomy:Butitissurelyfar bettertopart withone
of the conveniences of Life, than to part with Life itself.
Besides, the excrements thatare voided by thispassage,
arenotaltogethersooffensive,asthosethatarevoidedper
anum.
LorenzHeister
This is perhaps the right time and place to discuss general concepts concerning the
constructionofintestinalstomata.Mr.Cheetham kindly agreed to share lessonsfromhisvast
experience.Youwillreadmoreaboutspecificindicationsforsmallorlargebowelstomatainthe
relevantindividualchapters.TheEditors
Thereareonlytwoindicationstocreateastoma;whenyou
wanttoandwhenyouneedto.
R.JohnNicholls
Patients and surgeons have differing views of stomata. For a
psychologically unprepared patient who recovers from emergency
surgery,astomaisadevastatinginsulttotheirbodyimageandsexuality.
Tothesurgeon,astomamaybeseenasaninsulttoprofessionalpride;
its mere presence implies that he cannot even join a piece of bowel
togetherproperly.Gotoanysurgicalconferenceandyouwillseepapers
on how clever surgeons completely avoid stomata with their
robotic/SILS/blah,blahblah…
Butcommon-sensesurgeons know that awell-madestoma in the right settingcanbe
life-saving(andalsoimprove the quality of lifeforsome patients — but that’sanother
story).InthischapterIwilldiscussthewhysandwhereforesofcommonstomataand
alsosometipsformoreunusualsituations.
Theemergencystoma:whyandwhen
The most common reason to create a stoma as part of an
emergency abdominal operation is that the risk of anastomotic
leakage is consideredtoo high. For example, during an operation to
correctaleftcolonanastomoticleakitisusuallywisetoeitherexteriorize
the leak or if this is not possible, then completely take down the
anastomosis by stapling off the distal limb and creating a proximalend
stoma(àlaHartmann).
Onecould summarizethemostcommon indicationsfora stoma
inemergencysurgeryasfollows:
•
Surgeryforanastomoticleak.
•
Surgeryforfecalperitonitis.
•
Bowelresectioninapatientwithmajorrisksforleakage.
•
Surgeryforfulminantcolitis.
•
Toallowhealingofaperinealwoundorsepsis.
•
Todivertaboveanentercutanousfistula.
There are a few types ofstomata fromwhich tochoose forthe
aboveindications:
•
Endcolostomy.
•
Loopcolostomy(sigmoidortransverse).
•
Double-barrelcolostomy.
•
Blowholes.
•
Cecostomy.
•
Endileostomy.
•
Loopileostomy.
•
Jejunostomy.
•
Ileocolostomy(double-barrel).
Howtomakeanemergencystoma
Sitingastoma
Figure14.3.The‘triangleofstomata’.
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