Step 1: Surgical Anatomy

  • The submucosal layer of the bowel is the strongest layer of the intestines, and regardless of the anastomotic technique must be incorporated in all anastomosis.

Step 2: Preoperative Considerations

  • The technique for small bowel resection varies depending on the clinical presentation, intraoperative findings, and location along the alimentary tract. It is preferable to utilize both stapled and hand-sewn techniques. Stapled anastomosis can be performed rapidly, accurately, and with a lower leak rate than hand-sewn anastomosis in some series. However, when there is a discrepancy in diameter secondary to obstruction or the resection is far proximal, a sutured anastomosis is preferable. Both techniques are described here.

Step 3: Operative Steps

Stapled Anastomosis

  • A window is created between the mesenteric wall of the bowel and the mesentery between vascular arcades with the assistance of cautery and a curved clamp. This is done proximally and distally in an area of viable tissue or with an adequate margin in oncologic resections. ( Figure 23-1AB )

    Figure 23-1

  • The GIA 60-mm length, 3.8-mm height, linear cutting stapler, is then applied and inserted through the window at a slightly oblique angle. ( Figure 23-2AB )

    Figure 23-2

  • The linear cutting stapler is fired from the antimesenteric to the mesenteric side to transect the intestine.

  • The mesentery is then divided between Kelly clamps. ( Figure 23-3AB )

    Figure 23-3

  • In oncologic resection the primary vessel supplying the segment is divided at its base to harvest sufficient lymph nodes.

  • The vascular supply to the segment is then tied as the clamps are removed and the specimen is handed off the field.

  • The two stapled ends are brought in close proximity and aligned in a parallel fashion, and the base of the mesentery is examined to be sure there is no abnormal rotation.

  • A towel is brought on the field to prevent any unnecessary spillage of enteric contents into the abdominal cavity.

  • Two Alice clamps are placed on the stapled antimesenteric corner of each end; the corner is removed with a curved Mayo scissor; and the clamps are replaced in the lumen of the bowel and applied full thickness to the outer serosa.

  • One limb of the GIA 60-mm, 3.8-mm linear cutting stapler, is inserted in each end of the bowel where the enterotomy was made, and the stapler is joined in the intermediate locking position. ( Figure 23-4 )

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