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104 Moshe Schein · Roger Saadia
indication for “on-demand” abdominal re-exploration was thought to be at best
questionable. Hence, the emergence of an aggressive management approach in
the form of planned relaparotomy and open management of the abdomen (laparostomy). These two modalities were often combined.
Planned re-laparotomy pushes the process of source control to its limit. By
staging repeated operative interventions to follow the first “index” procedure for
peritonitis, the surgeon makes a commitment to return to the abdominal cavity
again and again to re-explore, evacuate, wash out, debride, or resect as needed until
the disease process is definitively controlled (> Chap. 52.1). This dogged pursuit
is justified by local intra-abdominal conditions rather than the patient’s overall
status.
Open management (laparostomy) is, in concept, an extension to peritoneal
toilet by providing maximal drainage for the purulent abdomen. It facilitates
frequent re-explorations. We now know also that it serves as a prevention of the
abdominal compartment syndrome (> Chaps. 40 and 52).
Early results of these methods seemed promising, particularly in the management of infected pancreatic necrosis but were less favorable in cases of postoperative peritonitis, perhaps because the sickest patients were included. Intestinal
fistulas plagued simple open management, but this problem was somewhat minimized by the introduction of modern temporary abdominal closure (TAC) techniques (> Chap. 52.2).
Recent prospective randomized studies, imperfect as they were given the difficulties in patient enrollment and stratification, failed to show an advantage for
the planned re-laparotomy policy and pointed to a higher complication rate (in
surgery, there is no free lunch). The possibility was raised that relaparotomies
constitute a “second hit” in patients in whom the inflammatory response was already “switched on,” escalating the SIRS (> Chap. 54). It is more likely, though, that
sick patients were subjected to a double iatrogenic insult: frequent trips out of the
intensive care unit (ICU) and intempestive surgical manipulations. Is there still a
place for the “aggressive management”? We believe there is one, in a very small
minority of carefully selected patients at the hands of expert teams. Wholesale
application or relegating the relaparotomy performance by junior staff to the end
of the operating room (OR) slate are recipes for disaster (> Chap. 52).
Our indications for these modalities are summarized in > Table 12.1.
Need for Peritoneal Cultures
At age 70, Average Citizen undergoes a laparotomy for a perforated sigmoid
diverticular disease with generalized fecal peritonitis. Are you one of those sur-
12 Peritonitis: Contamination and Infection—Principles of Treatment 105
>
Table 12.1. Indications for laparostomy/planned relaparotomy (
Critical patient condition (hemodynamic instability) precluding appropriate ·
source control at the first operation, thus calling for “abbreviated laparotomy”
or “damage control” strategy
Excessive peritoneal (visceral) swelling preventing tension-free abdominal clo-·
sure (abdominal compartment syndrome;
Massive abdominal wall loss·
Inability to eliminate or to control the source of infection·
Incomplete debridement of necrotic tissue·
Uncertain viability of remaining bowel (·
Uncontrolled bleeding (the need for “packing”)·
> Chap. 40)
> Chap. 23)
Chap. 52)
geons who would send a specimen of peritoneal fluid for culture? If so, how often
do you follow up the results and modify accordingly your antibiotic regimen?
What indeed can be gained by culturing Mr. Average Citizen’s feces?
This is a typical example of secondary peritonitis that is community acquired (i.e., Mr. Average Citizen perforated his colon at home and then walked in
through the emergency room doors). The microbiology of this type of IAI is predictable and responds readily to an empiric broad-spectrum antibiotic regimen,
initiated preoperatively, that includes antianaerobic cover (> Chap. 7). In any
case, culture results would become available well after the completion of the antibiotic course (> Chap. 47).
Peritoneal cultures are useful in the following scenarios:
Primary peritonitis for which there is no intra-abdominal source of infection;
the fluid contains an organism that has migrated from somewhere else
Secondary peritonitis when it is nosocomial (acquired in an already hospi-
talized patient), the best example being postoperative peritonitis
Tertiary peritonitis, which is commonly associated with a peculiar micro-
biology (> Chap. 54)
Peritonitis in the immunocompromised patients (AIDS) and those already
on antibiotics
(If you want to read much more about this topic, then find a copy of Source
Control, edited by M. Schein and J. Marshall, Springer, Berlin, 2002.)
“Shakiness of the hand may be some bar to the successful performance of an
operation, but he of a shaky mind is hopeless.” (Sir William MacEwen, 1848–1924)
The Intestinal Anastomosis
Moshe Schein
Best is the enemy of good ... the first layer is the best—why spoil it?
The Ideal Anastomosis
The ideal intestinal anastomosis is the one that does not leak, for leaks, although relatively rare, represent a dreaded and potentially deadly disaster
(> Chap. 50). In addition, the anastomosis should not obstruct, allowing normal
function of the gastrointestinal tract within a few days of construction.
Any experienced surgeon thinks that his or her anastomotic technique, adopted from mentors and with a touch of personal virtuosity, is the “best.” Many
methods are practiced: end to end, end to side, or side to side; single versus double layered, interrupted versus continuous, using absorbable versus nonabsorbable and braided versus monofilament suture materials. We even know some
obsessive-compulsive surgeons (do you know any?) who carefully construct a
three-layered anastomosis in an interrupted fashion. Now, add staplers to the
mix. So, where do we stand; what is preferable (> Fig. 13.1)?
13
Pros and Cons
Numerous experimental and clinical studies support the following:
Leakage: the incidence of anastomotic dehiscence is identical—irrespective
of the method used—provided the anastomosis is technically sound; constructed
with well-perfused bowel without tension; and water—and airtight.
Stricture: the single-layer anastomosis is associated with a lower risk of
stricture formation than the multilayered one. Strictures are also more common
following end-to-end anastomosis performed with the circular stapler (especially when the smaller sizes are used).
Misadventure: intraoperative technical failures with staplers are more fre-
quent due to “misfires.”
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_13, © Springer-Verlag Berlin Heidelberg 2010
107
108 Moshe Schein
Fig. 13.1. “Give it to me, nurse. … This will be a perfect anastomosis!”
Speed: stapled anastomoses, on the average, are slightly faster than those
sutured by hand. The fewer the layers, the faster the anastomosis is, and the
continuous method is swifter than the interrupted one. In practice, the time
consumed in placing two hand-fashioned “purse-string” sutures for a stapled
circular anastomosis is identical to that required to complete a hand-sutured,
single-layered, continuous anastomosis.
Suture material: braided sutures (e.g., silk or Vicryl) “saw” through tissues
and, experimentally at least, are associated with greater inflammation and activation of collagenases than monofilament material (e.g., PDS, Prolene). “Chromic
catgut” is too rapidly absorbed to support (alone) an anastomosis. Monofilament
slides better through the tissues and, when used in a continuous fashion, is selfadjustable, allowing equal distribution of the tension around the entire circumference of the anastomosis.
Cost: staplers are much more expensive than sutures and thus generally not
cost-effective. The single-layer continuous technique requires less suture material and is therefore more economical than the interrupted method.
The Choice of Anastomotic Technique
Since all methods, if correctly performed, are safe, nobody can fault you
for using the anastomotic method with which you are most familiar and
13 The Intestinal Anastomosis 109
comfortable. We maintain, however, and we may be biased, that the one-layer,
continuous method, using a monofilament suture material, is the one that a
“modern surgeon” should adopt because it is fast, cheap, and safe. What is good
for the high-pressure vascular anastomosis should be as good for the low-pressure intestinal one. If the first layer suffices, why narrow and injure it with inverted and strangulated tissue? Would you replace a well-done hamburger on the
grill? As with any beautiful piece of art, less is more.
We acknowledge that staplers are elegant, admired by the nursing operating room staff, “fun” to use, and of great financial benefit to the manufacturers.
Certainly, staples may be advantageous in selected “problematic,” rectal, or
esophageal anastomoses, deep in the pelvis or high under the diaphragm. But,
those types of anastomoses are seldom performed in emergency situations.
Furthermore, as a surgical trainee you should start using the staplers only after
achieving maximal proficiency in manual techniques and in difficult circumstances. Even the stapler aficionado has to use hands when the instrument misfires or cannot be used because of specific anatomic constraints, such as the
retroperitoneal duodenum. The modern surgeon, and the trainee, need to be
equally proficient in hand-sewn and stapled anastomotic techniques; we suggest,
however, that before driving a truck you should be able to manage a car.
The Edematous Bowel
There is some evidence (not level I) that, in trauma patients, stapled intestinal anastomoses are more prone to leak than the hand-sewn ones. This has
been attributed to the postresuscitation bowel edema that develops after severe
injury. (The staplers cannot “adjust” to the swelling of the bowel; the surgeon’s
hands can.) It is also our experience that a continuous, monolayer anastomosis
occasionally fails when performed in edematous bowel (e.g., after massive fluid
resuscitation or severe peritonitis). From findings at reoperation, we have learned
that subsequently, as the bowel edema subsides, the suture becomes loose, leading to anastomotic dehiscence. 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”—not only to avoid cutting through the bowel
edges but also to obviate the risk of loosening after the edema subsides. 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 this situation the ability of the colon to change
dramatically in diameter under normal physiological conditions may be impaired if a continuous suture with its fixed length is utilized. We admit, however,
that scientific data to back these hypotheses are lacking.
110 Moshe Schein
Technique
Our preferred continuous, monolayered anastomosis uses one doublearmed, or two regular, 3–0 or 4–0 monofilament sutures (PDS or Maxon). No
bowel clamps are used as we like to assess the adequacy of blood supply to the
bowel edges. It is not necessary to devascularize the bowel edges by “cleaning
off” the fat at the mesenteric side or removing appendices epiploica. The suture
line begins at the posterior/mesenteric wall, running “over and over” toward
both sides to meet, and be tied, anteriorly (at the antimesenteric border). The
secret is to take generous bites through the submucosa, muscularis, and serosa
and avoid the mucosa (“big bites outside, small bites inside”), thus inverting it.
This suturing technique is known variously as extramucosal or serosubmucosal.
The needle exit or entry site on the serosal side is 5–7 mm from the bowel edge
(even 1 cm or more when the bowel is thin or edematous—“too big bites can’t
harm but too small can leak”), while the distance between the bites should be
such as not to allow access to the tips of a Debakey forceps (3–4 mm). The assistant who “follows” the suture should use just enough tension to maintain approximation and avoid strangulation of the tissue (a reliable assistant is crucial).
In addition to the end-to-end situation, this technique suits also both the end-toside and side-to-side versions, and in essence, it is the intestinal version of a
routine vascular anastomosis except that the vascular one is “everted.” We use
this technique throughout the entire gastrointestinal tract, from the esophagus
to the rectum. Essentially, you create an inverted and safe anastomosis, with a
wide lumen, using only a suture or two, in less than 15 min.
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 advantage mentioned. For this purpose, we use Vicryl sutures, 3–0 or 4–0, which are easier to
tie than monofilament. Again, we start with the posterior wall and progress, alternately, on each side to meet at the front. Like with the continuous method, we
take big bites on the outside and tiny on the inside, inverting the mucosa. All
sutures, except the last few at the front, are tied inside the lumen.
A Few More Words on Staplers
Correct use of staplers is something you will learn from your mentors. In
fact, unlike what you may think, we are not rigidly “staplerophobic.” We use
staplers generously in emergency situations to occlude, rather than anastomose;
a classical 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 ileocolic anastomosis after,
13 The Intestinal Anastomosis 111
respectively, small bowel resection or right hemicolectomy—using a linear cutting (GIA) and linear occluding (TA) staplers makes sense to us. But, a side-toside gastrojejunostomy, when you insert the GIA into the stomach and small
bowel through two holes, which you then have to close with sutures, makes no
sense as the combined size of the gastric and jejunal enterotomies is almost that
of the gastrojejunostomy you could have created and sutured by hand. Moreover,
these enterotomies, which are used to insert the jaws of the linear cutting staplers
and are then closed by hand, seem to be the Achilles’ heel of the anastomosis:
they, rather the stapler line, are often the site of a leak.
Testing the Anastomosis
A correctly performed anastomosis should not leak. There is little point in
routinely testing your simple intra-abdominal intestinal anastomosis; the common practice of pinching-masturbating the anastomosis to confirm an adequate
lumen is laughable if you used a one-layer technique as described. Problematic
anastomoses, such as those performed in the lower rectum, should be tested:
simply clamp the bowel above the anastomosis, fill the pelvis with saline, and
inject air into the rectum. Instead of air, you may wish to use dye. If air bubbles
(or dye) are observed leaking, an attempt to identify and correct the defect is
indicated; if unsuccessful or doubtful, a proximal diverting stoma is necessary.
When Not to Perform an Anastomosis
We wish we had an exact answer regarding when to perform an anastomosis. In broad terms, whenever the probability of a leak is high, avoid an anastomosis since any anastomotic leak portends disastrous consequences (> C ha p . 5 0).
But, how do you accurately predict anastomotic failure?
Traditionally, the avoidance of colonic suture lines during emergency operations for trauma, obstruction, or perforation was the standard practice. But,
times are changing. During World War II, a colostomy was mandatory for any
colonic injury; now we successfully repair most of these wounds (> Chap. 39.2).
Furthermore, three- or two-stage procedures for colonic obstruction have been
replaced by the one-stage resection with anastomosis (> Chap. 25). And, as you
will read in > Chaps. 25 and 26, the issue of whether the large bowel is “prepared”
or not has become a nonissue. Multiple prospective randomized trials have
shown that safe colorectal suture lines can be effected in unprepared bowel.
It is difficult to lay down precise guidelines regarding when an intestinal
anastomosis is not to be made. You should make a careful decision after considering the condition of the patient, the intestine, and the peritoneal cavity.
112 Moshe Schein
Table 13.1. Factors that may influence us not to anastomose
Diffuse established peritonitis·
Postoperative peritonitis (·
Leaking anastomosis (·
Mesenteric ischemia (·
Extreme bowel edema/distension·
Extreme malnutrition with low serum albumin (·
Chronic steroid intake·
Unstable patient (damage control situation) (·
Generally, we would avoid a colonic anastomosis in the presence of established
and diffuse intra-abdominal infection (as opposed to contamination) (> C h a p . 2 6)
and under the conditions listed in > Table 13.1. Regarding the small bowel, anas-
tomosis is indicated in most instances; however, when more than one of the factors listed in the table are present, we would tend to err on the conservative side
and exteriorize or divert, depending on technical circumstances.
No formula or algorithm is available, so use your judgment and try not to
be too obsessive in always attempting an anastomosis. Yes, we know that you
wish the patient well by wanting to spare the patient a stoma, but he or she will
not be impressed if 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 reinfusion, somatostatin, and stoma care, these temporary proximal intestinal “vents” can be lifesaving
(see also > Chaps. 46 and 50). On the other hand, do not be a wuss by avoiding
an anastomosis when it is indicated and possible.
Whatever you do, some people will be unhappy. If you do a colostomy, there
will be always someone to ask you, why not primary anastomosis? If you do a
primary anastomosis, there will be always someone to say, why not colostomy?
Only being a football coach is worse is this regard.
>
>
Chap. 50)
>
Chap. 23)
Chap. 52)
>
Chap. 46)
>
Chap. 39)
Conclusions
The intestinal anastomosis is the “elective” part of the emergency operation you are going to perform. Remember—your aim is to save life and minimize
morbidity; create an anastomosis when its chances of success are at least reasonable. There are many ways to skin a cat and to fashion an anastomosis. Master a
few methods and use them selectively.
Intestinal Stomas
Luis Carriquiry
Throughout surgical history, surgeons have viewed the creation of an intestinal stoma with distaste but, at the same time understood its potential lifesaving
value—as reflected by these two quotations from master surgeons:
Of all the diseases to which man is liable, there is no one so 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 intestines are constantly
escaping. (Guillaume Dupuytren, 1777–1835)
About colostomy: But it is surely far better to part with one of the conveniences
of Life, than to part with Life itself. Beside, the excrements that are voided by this
passage, are not altogether so offensive, as those that are voided per anum. (Lorenz
Heister, 1683–1758)
14
Nobody likes an operation that results in an intestinal stoma, neither the
patients, who habitually hate the mere idea of them, nor the surgeons, who may
look at stomas as a mark of failure. But, the creation of a stoma may be a lifesaving procedure, so they deserve particular attention. A large part of the bad reputation of stomas results from poor stoma creation technique. In contrast, properly
created stomas are easier to manage in the postoperative period (sometimes for
the rest of the patient’s life) and lighter to bear as an incapacity. So, even after a
long, difficult, and tiresome emergency operation, you have to pay due attention
to technical details in the performance of the stoma and not “pass the buck” to
an insufficiently trained assistant.
Intestinal stomas are created when the large or small bowel is exteriorized
through the abdominal wall. The only exception to this is the tube cecostomy, in
Luis Carriquiry
Maciel Hospital School of Medicine, Universit y of the Republic, Montevideo, Uruguay
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_14, © Springer-Verlag Berlin Heidelberg 2010
113
114 Luis Carriquiry
which communication to the exterior is indirect via a tube (e.g., Pezzer, Malecot,
or Foley). The current indications for this are few and may include Ogilvie’s syndrome or cecal volvulus (> Chap. 25).
Intestinal stomas can be either:
Ter mi na l or “end” stomas—when the surgeon exteriorizes the proximal
limb of the transected bowel
Lateral or “loop” stomas—when the surgeon exteriorizes a loop of nonin-
terrupted bowel and makes a hole in its apex
Both types of stomas fully divert the bowel content to the exterior. This is
obvious in the case of end stomas but has been debated in the case of loop stomas;
now the debate is settled, and everyone accepts that feces are incapable of finding
their way to the distal bowel in a correctly fashioned loop stoma.
Turnbull’s (Rupert Beach Turnbull Jr., 1913–1981) criteria for optimal stoma
construction have withstood the test of time:
Proper location
Adequate abdominal wall aperture
Tension-free intestinal exteriorization
Adequate blood supply to the exteriorized segment
Immediate maturation of the mucosa of the stoma
The Site of the Stoma
In the emergency setting, the surgeon does not have the help of a stoma
therapist or the possibility of experimenting with the appliance in different positions before the operation. But, this is not an excuse for not trying to choose the
best site, which is:
Lateral, half the way along a line drawn from the umbilicus to the superior
iliac spine
Not very near to the umbilicus, the costal margin, or the iliac spine
Preferably through the rectus abdominis muscle
Away from creases in the skin, especially in obese patients
Away from scars
But, of course, unusual sites of stomas in the bowel (e.g., proximal small
bowel, transverse colon) could force us to compromise with an unconventional
and nonperfect abdominal wall site.
In addition, it has been said: “Bringing a colostomy out through a laparo-
tomy incision is like putting a toilet in the kitchen.”
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