Anastomotic Construction Techniques

Matthew F. Kalady

Perioperative Considerations

There are a variety of ways to construct safe and effective bowel anastomoses.
No one particular anastomosis is considered “the best,” and the method selected is often made based on surgeon preference, the clinical situation at hand, and experience.
Surgeons should be aware of various anastomotic techniques, using staplers or sutures.
It is imperative that surgeons use clinical judgment to decide which anastomotic technique is most appropriate for each individual case based on anatomy, quality of tissue, and patient- and disease-related factors.
The anastomotic technique may also rely on the availability of particular instruments, instrument malfunction, and technical feasibility.
Clinical judgment, especially regarding when not to do an anastomosis, is equally important as how do construct one.
- Patients with severe malnutrition, immunosuppression, sepsis, shock, or fecal contamination should be considered for a stoma without an anastomosis.

General Technical Considerations

Use healthy tissues for anastomosis.
Ensure adequate blood supply to both ends of the bowel.
Mobilize both ends of the bowel to avoid tension.
Align corresponding mesentery without twisting or torsion.

Types of Anastomoses Based on Anatomy

ENTEROENTERIC OR ILEOCOLONIC ANASTOMOSES

Perioperative Consideration/Approach

Enteroenteric anastomoses are commonly performed for small bowel resection for Crohn disease (see Chapter 41), radiation enteritis, closure of ileostomy (see Chapters 43 and 44), enterocutaneous fistulas (see Chapter 27), and resection of small bowel neoplasms.
Ileocolonic anastomoses are commonly used after ileocolic resection for Crohn disease (see Chapter 41) or right colectomy for colon cancer (see Chapter 22).

Equipment

Stapling devices (Fig. 19-1):

FIGURE 19-1 ▪ Different types of surgical staplers used in the construction of bowel anastomoses. A. Linear cutting stapler. B. Transverse anastomosis (TA) linear noncutting stapler. C. Laparoscopic articulating linear cutting stapler. D. PI linear noncutting stapler. E. Circular end-to-end anastomosis (EEA) stapler.

Linear cutting single-use reloadable stapler (linear cutting, 60 or 80 mm length), 3.8-mm staple height
Linear noncutting (60-mm length, 3.8- or 4.8-mm staple height)
End-to-end anastomosis (EEA) circular stapler (3.5-mm staples, 28, 31, or 33 mm diameter)

Suture: Vicryl, polydioxanone (PDS), ethibond of various needle shape, sizes, and thickness

Techniques

Side-to-side (functional end-to-end), stapled
- Use wound protector to limit potential soilage of the wound edges.
- Clear mesenteric borders and ligate mesentery.
- Staple across bowel using a linear stapler at a healthy area of bowel.
- Staple line should be parallel to the mesentery and go across the bowel in the same plane from the mesenteric edge of the bowel to the antimesenteric border.
- Place the tips of the stapler on the antimesenteric side.
- Angle the stapler away from the mesentery so that the antimesenteric edge is slightly shorter than the mesenteric edge (Fig. 19-2A).
Open the antimesenteric corners of the staple line and anchor with Allis clamps (Fig. 19-2B).
Place one arm of the stapler down each limb of the bowel (Fig. 19-2C).
Align the antimesenteric borders and close the stapler, place fingers beneath the bowel and spread, pushing the mesentery laterally to ensure that the antimesenteric borders are in the anastomosis (Fig. 19-2D), then fire the stapler.

Close the common enterotomy (Fig. 19-2E) with a linear noncutting stapler such as a transverse anastomosis (TA) stapler (Fig. 19-1), 3.8- or 4.8-mm staple height.

Ensure no bleeding from bowel staple lines.
Stagger the bowel staple lines when aligning to close enterotomy.
Ensure mucosa, submucosa, and serosa are all elevated and into the stapler; check again after closing the stapler, before firing.
Resect the remaining edge distal to the staple line with a scalpel; there will be some resistance as the scalpel cuts across the small bowel staple lines.

Ensure hemostasis on the transverse staple line.

FIGURE 19-2 ▪ Stapled side-to-side anastomosis. An ileocolic anastomosis is shown. A. Use a linear stapler to divide across the bowel. Note that the angle of the stapler is toward the side of the bowel that will remain for the anastomosis so that there is improved blood flow to the antimesenteric bowel wall. B. An enterotomy is made on the antimesenteric corners of the staple line in the small bowel and a corresponding colostomy in the colon. The openings are exposed with the use of Allis clamps. C. The linear stapler is inserted into each limb of bowel, and the antimesenteric bowel walls are aligned. D. Before closing and firing the stapler, the surgeon’s hand is placed below the bowel and ensures that there is no mesentery or other tissue included in the anastomosis and that the antimesenteric walls are included. E. The common enterotomy is stapled across with a linear noncutting stapler. Allis clamps are used to extend the open end of the bowel to ensure that the full thickness of the bowel wall is incorporated in the stapler.

Imbricate the corners with 3-0 Vicryl sutures.
Reinforce the crotch of the anastomosis with 3-0 Vicryl suture.
- Alternatively, oversew the full staple line with interrupted 3-0 Vicryl sutures in Lembert manner.
Oversew the common enterotomy staple line with running 3-0 Vicryl stitch.
Alternatively, enterotomy can be closed with suture or with another linear cutting stapler.

The author prefers to use an omental pedicle flap (Fig. 19-3A and B) around an ileocolic anastomosis.

FIGURE 19-3 ▪ Omental pedicle flap over the anastomosis. A. The omentum is partially freed and mobilized from the remaining transverse colon to create a floppy omental flap. B. The omental flap is loosely secured to the bowel or mesentery with 3-0 Vicryl sutures.

Side-to-side (functional end-to-end), sutured
- As earlier, the proximal and distal margins of the bowel are stapled across and divided.
- Alternatively, they can be sewn closed.
- Antimesenteric borders are aligned and stay sutures placed to align the two segments of the bowel (Fig. 19-4A).
- Posterior layer of a running 3-0 PDS suture through the seromuscular layers is placed to appose the two limbs of bowel (Fig. 19-4A).
- Longitudinal enterotomies are made (Fig. 19-4B).
- The posterior walls of the bowel are sutured together with a full-thickness 3-0 PDS running stitch, focusing on incorporation of the submucosal layer. There are two initial sutures placed in the middle of the backwall and then run to opposite ends of the anastomosis (Fig. 19-4C).
- The suture transitions to a Connell suture at the corners and along the anterior wall (Fig. 19-4D).
- The anterior second layer of the anastomosis is completed with interrupted 3-0 PDS Lembert, imbricating the stitches (Fig. 19-4E). This layer can also be done as a running suture if preferred.
- The author prefers PDS suture for running anastomosis for its ease of passage through the tissue.

End-to-side anastomosis, stapled

Divide both ends of the bowel between clamps sharply.
Open bowel lumens and ensure adequate health and blood supply.

Assess for size of stapler that will be accommodated by small bowel lumen.

FIGURE 19-4 ▪ Sutured side-to-side anastomosis. An ileocolic anastomosis is shown. A. The antimesenteric bowel walls are aligned, and stay sutures are placed to help with alignment and retraction. A posterior wall running suture is then placed as the deep layer of the anastomosis. B. Longitudinal enterotomy and colostomy is made in each limb of bowel, respectively. C. The inner layer of the posterior wall is completed with running full-thickness sutures. D. Detailed view of the transition of the corner stitches and Connell stitch on the anterior wall inner layer of the anastomosis. E. Completion of the outer layer of the anterior wall with Lembert sutures. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

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