Principles of bowel anastomosis

intestinal anastomosis, bowel anastomosis, small bowel resection,

1. PRINCIPLES OF BOWEL
ANASTOMOSIS
DR BASHIR YUNUS
GENERAL SURGERY UNIT PRESENTATION
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2. OUTLINE
•INTRODUCTION
•TYPES
•INDICATIONS
•PRE-OPERATIVE PREPARATION
•INTRA-OPERATIVE PRINCIPLES
•POST-OPERATIVE CARE
•COMPLICATIONS
•CONTROVERSIES
•REFERENCES
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3. 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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4. 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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5. 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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6. INDICATIONS
•Restoration of continuity following resection of bowel disease;
•Gangrene
•perforation
•Malignancy
•Benign conditions-polyps, intussusception
•Radiation enteritis
•Infections egTb with stricture
•Bypass of unresectable disease bowel
•Advanced tumourcausing luminal obstruction
•Metastatic disease causing obstruction
•Congenital anomalies-intestinal atreasia, Hirschsprungdisease.
•Bilo-pancreatic diversion
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7. PRE-OPERATIVE PREPARATION
•Resuscitation
•Optimization; dehydration, anaemia, infection, nutrition
•Bowel preparation (and avoidance of spillage)
•Antibiotic prophylaxis
•DVT prophylaxis
•Counseling
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8. Intra-operatives
•Anesthesia
•GA and muscle relaxation
•Maintenance of good perfusion and tissue oxygenation
•Adequate access and exposure
•Lightening
•Assessment of Viabilityof bowel
•Prevention of spillage -Clamping
•Avoid clamping or suturing mesenteric vessels
•Decompression
•Blood supply-bright red bleeding from cut edge
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9. •Meticulous technique
•Tension-free
•Appropriate sutures
•Inverting edges
•Adequate resection margins
•Ensuring patency
•Negociatingcaliber; 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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13. SINGLE LAYER ANASTOMOSIS
•An interrruptedseromuscularsuture, with absorbable thread. The
submucosallayer is strong and the blood supply is only minimally
damaged
•Lembert stitch
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16. DOUBLE LAYER ANASTOMOSIS
•An inner continuous absorbable
suture, with stitching of all
layers
•An outer, seromuscular,
interrupted nonabsorbable
suture
•Serosa apposition and mucosa
inversion; the inner layer has a
hemostatic effect, but the
mucosa is strangulated
•Connell stitch-continuous
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21. 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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24. Postoperative care
•Nil per Osabout 5days
•N-G tube
•Iv fluid
•Antibiotic
•Analgesics
•PCV, U/Ecrcheck
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25. Complications
•Bleeding
•Anastomotic leak
•Wound infection
•Intra-abdominal abscess
•Obstruction
•Stricture
•Prolonged ileus
•Recurrence
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26. CONTROVERSIES
•Inversion versus eversion
•Abdominal drains
•N-G tube decompression
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27. •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
oedemaand inflammation with evertedsmall bowel anastomosis
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28. 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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29. •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 perianastomoticdrain in dogs
•Another study showed inflammation around the anastomosis
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30. 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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31. References
•Bailey and Loves short practice of surgery, 25th edition
•Khatri: Operative Surgery Manual, 1st ed
•Kirk’s general surgery operations 6
th
edition
•Farquharson’stextbook of operative general surgery 9
th
edition
•Borossurgical technique
•SRB’s surgical operation text and atlas 1
st
edition. 2014
•www.emedicine.emedcape.com
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