Anastomotic Construction
This chapter summarizes the various techniques for common abdominal and pelvic anastomoses. General principles of anastomotic construction are summarized, including a review of the basic anastomotic types, techniques, equipment, and common problems leadin
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Key Concepts • Benign effluent from a peri-anastomotic drain does not rule out anastomotic leak or abscess. • It is safe practice to leave the mesenteric defect open after constructing an ileocolic anastomosis. • Fecal diversion reduces septic complications in patients with coloanal anastomoses. • Diverting loop ileostomy and loop colostomy have similar complication rates. • Leak testing should be performed on anastomoses to the rectum.
Introduction The purpose of this chapter is to review the various anastomotic techniques for abdominal and pelvic anastomoses. There are many unique and innovative ways to create anastomoses; however, this chapter will focus on the most common techniques and the problems associated with their construction. It is difficult to overemphasize the importance of judgment and technique in preventing anastomotic complications while still preserving function. Various clinical situations and differing anatomy make it important to be familiar with multiple approaches to the same type of anastomosis. Knowledge of these various techniques is of paramount importance in achieving good outcomes. No matter how well planned the creation of an anastomosis is, problems will arise during execution, and the ability to salvage an anastomosis is a skill every colorectal surgeon must master.
Electronic supplementary material: The online version of this chapter (doi:10.1007/978-3-319-25970-3_9) contains supplementary material, which is available to authorized users.
General Principles of Anastomoses Surgical Staplers Rudimentary surgical staplers first appeared in the early 1900s, but stapling devices improved dramatically in the 1970s with preloaded disposable cartridges of multiple staggered staple lines. Titanium staples have replaced stainless steel and are found in a variety of staple heights that are bent into a “B” configuration in order to match tissue thickness. Surgical staplers can be divided into two major groups: linear and circular. The simplest linear stapler (TA or thoracoabdominal) applies two rows of staples in a staggered configuration but requires manual transection of the bowel. The linear cutting stapler (GIA or gastrointestinal anastomosis) applies four rows of staggered staples and cuts between the middle two rows of staples, allowing for the division of bowel and the creation of anastomoses. Circular staplers (e.g., EEA or end-to-end anastomosis) have a detachable anvil. Once the anvil and head are coupled together, two circular rows of staggered staples are applied as a circular blade cuts out the interior tissue, allowing communication of the two lumens. EEA staplers come in a variety of diameters, with 25–31 mm staplers being the most common in colorectal surgery [1].
Hand-Sewn Anastomoses Gastrointestinal anastomoses have been performed by various hand-sewn techniques for many years. Single-layer and double-layer anastomoses have been studied extensively, and a lone randomized controlled trial and three comparative studies have shown no difference in anastomotic leak rates between
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