Intestinal anastomosis and staplers

Presentation describing surgical technique and principles of anastomosis, factors for good healing in the post operative phase, risk factors for leak and the role of staplers in modern day surgical practice, advantages over hand sewn anastomosis.

1. INTESTINAL ANASTOMOSIS AND STAPLERS DR. SUDHIR JAIN M.B.B.S., M.S., M.B.A. (HCA), F.R.C.S., F.A.C.S., F.I.C.S. DIRECTOR-PROFESSOR DEPARTMENT OF SURGERY

2. “THE ENEMY OF GOOD IS BETTER: THE FIRST LAYER IS THE BEST—WHY SPOIL IT?”

3. Galen : coined the term anastomosis, meaning without a mouth. Defined as joining of two hollow viscera or tubular structures with the intention of joining. Need: Part of gut surgically removed Destroyed by trauma Distal obstruction

4. Types : Gut- Intestinal Anastomosis Vessel: Vascular anastomosis Urinary tract Biliary tract or pancreatic duct

5. timeline 1826- Lembert - sero -muscular technique of suturing 1893- Nicholas Sen – Two layer closure using Silk Halsted - Single layer closure, extramucosal 1963- Connell - single layer interrupted, full thickness Kocher - two layered technique with silk & catgut Current technique of single layer extra-mucosal- Matheson of Aberdeen 1926- Carrel - End to end vascular anastomosis

6. Ideal anastomosis Zero leak rates. Should promote early recovery of function. No vascular compromise at the incised or divided margins of a viscus. Should not narrow the lumen of a viscus. Easy to learn, teach and perform. Technique should preferably be quick to perform

7. Types of anastomosis End to End End to side Side to side

8. Intestinal anastomosis Joining two ends of similar type: Jejuno-jejunal , ileo-ileal , colo -colic Joining two ends of different type: gastro- jejunostomy , oesophago-jejunostomy Joining gut with another tubular structure: Hepatico-jejunostomy , Choledocho-jejunostomy , Pancreatico-jejunostomy

9. Healing of anastomosis Acute inflammatory Phase (Lag Phase) Proliferative Phase Remodelling Phase or Maturation Phase

10. Degradation of mature collagen starts in first 24 hours, up to 4 days, due to MMP POD 7 collagen synthesis starts, proximal to anastomosis and continues for 5-6 weeks After 6 weeks, tensile strength by cross-linking of collagen fibrils. Strength in the first 7-10 days is by the staple or suture holding capacity of existing collagen. Collagen synthesis is by fibroblast and smooth muscle cells.

11. techniques Hand-sewn Stapled Suture-less anastomosis Nd:YAG laser Tissue glue: Fibrin Glue

12. Pre-requisites for good anastomosis Adequate exposure & access Gentle handling of bowel Well vascularized bowel Absence of tension Good surgical technique Avoidance of fecal contamination

13. Factors increasing the rate of anastomotic leak Emergency Surgery Anaemia Previous Irradiation Unprepared Gut Infection Distal Obstruction Peritonitis Malnutrition Immunosuppressive drugs Malignancy Inflammation Tension

14. Choice of suture materia l An ideal suture material M inimal inflammation and tissue reaction P rovide maximum strength during the lag phase of wound healing Monofilament and coated braided sutures are most effective Interrupted sutures preferred over continuous: Peri-anastomotic O 2 tension lower with continuous sutures Narrowing of the lumen occurs with continuous sutures

15. CONTINUOUS SUTURE INTERRUPTED SUTURE

16. Single layer vs double layer Single layer are preferred over double layer Decreased operative time Less narrowing of intestinal lumen More rapid vascularization and mucosal healing Rapid increase in the strength of the anastomosis in the first few days Early return of normal bowel function as measured by r eturn of bowel sounds, passage of flatus and resumption of oral feeding

17. Types of single layer anastomosis Single layer interrupted extramucosal - Large bowel or small bowel anastomosis Single layer interrupted full thickness- Biliary surgeries. E.g. Hepatico-jejunostomy , choledocho-duodenostomy Single layer full thickness continuous- Gastro- jejunostomy . Continuous sutures help in achieving haemostasis

18. Full Thickness suture Extra-mucosal suture Sero -muscular suture

19. 2 layer anastomosis consists of: Inner layer: Full thickness, interrupted or continuous. Small bowel- continuous Outer layer: Sero-muscular, interrupted in colonic, continuous in small bowel or stomach

20. Principles of anastomosis No disparity between the two ends of lumen. If one end is narrower it can be enlarged by “ fish mouthing” of the end To prevent leakage of contents and to steady the two ends, non-crushing clamps or stay sutures to be applied across the gut Three types of suture can be used for anastomosis of the gut: All coat stitches: All layers of the gut are taken. A dvocated by Halsted E xtra-mucosal or sero-submucosal technique: All layers are included except mucosa . Submucosa is the strongest layer, as it contains plenty of collagen tissue S ero-muscular stitch: B ites taken through the serosa and part of the muscular layer. Also known as Lembert stitch. U sed as a second layer to strengthen the first layer

21. staplers

22. “Staplers are not a substitute for sound surgical technique in carrying out gut anastomosis”.

23. It is a technical equipment used to mechanically connect hollow organs, divide soft tissue or vascular structures Introduced by Hulti in 1908. Hulti's stapler weighed eight pounds (3.6  kg) Required two hours to assemble and load. Many hours were spent trying to achieve a consistent staple line and reliably patent anastomosis

24. Advantages- Saves time Helpful in difficult sites like rectum and high oesophagus where anastomosis is difficult Multiple anastomosis are required. E.g. Whipples’s , Radical cystectomy Disadvantages : Costly Reliant on technology

25. staples Made of titanium but have some amount of nickel Patients who have allergies to nickel, e.g. jewellery causes a rash, oozing , or itching, should discuss nickel allergies with their surgeon Cause little tissue reaction Non magnetic

26. Types of staples Vascular staples White cartridges or grey cartridges Intestinal stapling Blue or green cartridges Blue for Small Intestine , C olon Green for stomach, Rectum , Pancreas

27. uses Gut anastomosis In Gastrectomy Gastro- jejunostomy Esophago-jejunostomy Colonic resection Low anterior resection Thoracic surgery in pnemonectomy , lobectomy

28. Types of staplers Transverse Anastomosis Stapler (TA) Gastro-Intestinal Anastomosis Linear Cutter (GIA) Circular or End to End Anastomosis Stapler (EEA) Endoscopic Stapling device (Endo GIA gun) USED FOR GUT ANASTOMOSIS

29. 1. Transverse Anastomosis Stapler: Simplest type Puts two rows of B shaped staples Used to close enterotomy 2. Linear Cutter: 2 double staggered rows of staples C uts between the two rows

30. 3. Circular Stapler: Places double rows of staples in a circle and cuts within the circle Used in LAR, Gastro-oesophageal anastomosis or stapled haemorrhoidopexy

31. Staplers can produce: Functional End to End anastomosis Anatomical End to End anastomosis Side to Side anastomosis

32. Anastomosis using stapler Place 2 ends of the bowel side to side maintaining the orientation Insert two limbs of stapler, 1 in each end of bowel

33. Fire stapler to fuse two ends Wait for 1 minute

34. Inspect the staple line and close the enterotomy COMPLETE ANASTOMOSIS

35. Advantages of stapled anastomosis over hand-sewn Staples provoke minimal inflammatory response They provide support to the cut surfaces in lag phase (weakest phase of healing). S horten operating time especially in low pelvic, thorax , or high abdomen In case of tumors, recurrence at the staple line is much less than at the suture line as suture materials produce a more pronounced cellular proliferation Stapled anastomosis heals by primary intention while sutured anastomosis heals by secondary intention

36. Testing the anastomosis Used when anastomosis is performed at a difficult site. E.g. low ano -rectal, esophago -gastric or in complex anastomosis like ileo -anal pouch Tests: Underwater test- LAR, Esophago -gastric anastomosis Methylene Blue test- Gastric pouch surgery

37. Key points The ideal anastomotic technique is still to emerge Every surgical trainee must learn and master hand-sewn anastomotic techniques A stapled anastomosis is not superior to a hand-sewn one, but it may save time Staplers add to the cost of surgery There is no difference in leak rate between continuous and interrupted sutures following intestinal anastomosis

38. Vascularity of resected ends of gut should be ensured before joining them Abdominal drainage after intestinal anastomosis should be avoided except in cases of peritonitis or trauma. Single layer anastomosis scores over double layer technique in terms of time saving, less luminal narrowing and early return of postoperative bowel function.

39. Thank you