PRINCIPLES OF BOWEL ANASTOMOSIS

DR BASHIR YUNUS

GENERAL SURGERY UNIT PRESENTATION

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OUTLINE

• INTRODUCTION

• TYPES

• INDICATIONS

• PRE-OPERATIVE PREPARATION

• INTRA-OPERATIVE PRINCIPLES

• POST-OPERATIVE CARE

• COMPLICATIONS

• CONTROVERSIES

• REFERENCES

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INTRODUCTION

• The word anastomosis comes from the Greek ‘ana’, without, and ‘stoma’, a mouth, i.e. when a tubular viscus (bowel) or vessel is joined after resection or bypass without exteriorisation with a stoma.

• Intestinal anastomosis is the surgical connection of separate or severed bowel to form a continuous channel.

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INTRODUCTION

• Early phase (0–4days): There is an acute inflammatory response, but no intrinsic cohesion.

• Fibroplasia (3–14days): Fibroblast proliferation occurs with collagen formation.

• Maturation stage (>10 days): This is the period of collagen remodeling, when the stability and strength of the anastomosis increase

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TYPES

• Orientation of bowel• Side-to-side• End-to-end• End-to-side

• Technique • Hand sewed • Stapling technique

• Part of the bowel involved• Gastro-jejunostomy• Jejuno-jejunostomy• Ileo-colic anastomosis

• Base on the number of layers• Single • Double layer

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INDICATIONS• Restoration of continuity following resection of bowel disease;

• Gangrene

• perforation

• Malignancy

• Benign conditions- polyps, intussusception

• Radiation enteritis

• Infections eg Tb with stricture

• Bypass of unresectable disease bowel • Advanced tumour causing luminal obstruction

• Metastatic disease causing obstruction

• Congenital anomalies- intestinal atreasia, Hirschsprung disease.

• Bilo-pancreatic diversion

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PRE-OPERATIVE PREPARATION

• Resuscitation

• Optimization; dehydration, anaemia, infection, nutrition

• Bowel preparation (and avoidance of spillage)

• Antibiotic prophylaxis

• DVT prophylaxis

• Counseling

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Intra-operatives

• Anesthesia • GA and muscle relaxation• Maintenance of good perfusion and tissue oxygenation

• Adequate access and exposure

• Lightening

• Assessment of Viability of bowel

• Prevention of spillage - Clamping

• Avoid clamping or suturing mesenteric vessels

• Decompression

• Blood supply- bright red bleeding from cut edge

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• Meticulous technique • Tension-free

• Appropriate sutures

• Inverting edges

• Adequate resection margins

• Ensuring patency

• Negociating caliber; cheating, cheatling- ‘cut-back’, oblique division of the bowel, side-to-side anastomosis, end-to-side

• Closure of mesenteric defect

• Drain –protection of anastomosis

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SINGLE LAYER ANASTOMOSIS

• An interrrupted seromuscular suture, with absorbable thread. The submucosal layer is strong and the blood supply is only minimally damaged

• Lembert stitch

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DOUBLE LAYER ANASTOMOSIS

• An inner continuous absorbable suture, with stitching of all layers

• An outer, seromuscular, interrupted nonabsorbablesuture

• Serosa apposition and mucosa inversion; the inner layer has a hemostatic effect, but the mucosa is strangulated

• Connell stitch- continuous

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Stapler-made anastomosis

• This can be a side-to-side anastomosis with a straight sewing machine (e.g. GIA = gastrointestinal anastomosis staplers).

• It can be an end-to-end anastomosis with a circular machine (e.g. CEEA = circular end-to-end anastomosis stapler).

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Postoperative care

• Nil per Os about 5days

• N-G tube

• Iv fluid

• Antibiotic

• Analgesics

• PCV, U/Ecr check

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Complications

• Bleeding

• Anastomotic leak

• Wound infection

• Intra-abdominal abscess

• Obstruction

• Stricture

• Prolonged ileus

• Recurrence

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CONTROVERSIES • Inversion versus eversion

• Abdominal drains

• N-G tube decompression

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• Traditionally ---inversion • Allows mucosal apposition

• ignores the base principles of accurately opposing clean-cut tissues

• Eversion • Study reported greater anastomotic strength, less luminal narrowing less

oedema and inflammation with everted small bowel anastomosis

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N-G tube ;• in retrospective and prospective, randomized controlled trials routine use of

NG tube conferred no significant advantage

• There was a trend of increase incidence of respiratory tract infection with gastric decompression.

• A study showed that 20% of patient required NG tube post operatively following gastric dilatation.

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• Abdominal drains• Collection around the anastomosis impair healing and leads to leakage

• Many surgeons place drain after anterior resection or colo-anal anastomosis because of risk of fluid collection

• a 1999 study of pelvic drainage after rectal or anal anastomosis showed that prophylactic drainage did not improve outcome or reduce complication

• One study showed a dramatic increase in the incidence of anastomotic dehiscence (15% to 55%) after placement of perianastomotic drain in dogs

• Another study showed inflammation around the anastomosis

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CONCLUSION

• Successful bowel anastomosis is attributed to adequate knowledge on intestinal healing, patient optimization, meticulous surgical technique and good post operative care.

• This is achieved by constant practice

• A complicated anastomosis is associated with increase morbidity and mortality as much as 10 fold and doubles length of hospital stay

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References

• Bailey and Loves short practice of surgery, 25th edition

• Khatri: Operative Surgery Manual, 1st ed

• Kirk’s general surgery operations 6th edition

• Farquharson’s textbook of operative general surgery 9th edition

• Boros surgical technique

• SRB’s surgical operation text and atlas 1st edition. 2014

• www.emedicine.emedcape.com

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