Stapled Coloanal and Colorectal Anastomoses
KEY STEPS
1. Exteriorization and resection of the pathology.
2. Insertion of the EEA stapler anvil in the proximal colon using a purse-string suture.
3. Return of the bowel to the abdomen.
4. Reinsufflation and anastomosis.
ADDITIONAL ADVICE
1. Our practice is to perform all anastomoses for diverticular disease to the rectum. Thus, the distal bowel cannot be exteriorized through any abdominal incision, as leaving this much distal bowel would necessitate a colocolic anastomosis.
2. Insertion with a downward, rotating motion and ample lubrication aids advancement of the circular stapler to the apex of the rectal stump.
3. Holding the anal verge with four Allis clamps can help provide countertraction, especially for very low rectal stumps and for stapled coloanal or ileoanal anastomosis.
4. Great care must be taken if any laparoscopic instrument is used to hold the rectal stump, as they can very easily perforate it or leave a tear in the serosa.
COLOANAL AND COLORECTAL ANASTOMOSES
For all of these procedures, the pathology has been exteriorized and resected, and a stapled anastomosis is now going to be performed. Pulsatile marginal bleeding is confirmed.
After exteriorization and resection, the anvil of an EEA stapling device is inserted using a handsewn purse string, and the bowel returned to the abdomen and the fascia closed. The abdomen is reinsufflated and the proximal colon found.
Orientation is confirmed by following the cut edge of the mesentery back to the retroperitoneum. Adequacy of reach is then determined by placing the colon with
anvil into the pelvis (Fig. 10.1). If it lies spontaneously, there will be no anastomotic tension. If the colon keeps falling back into the upper abdomen, then further mobilization of the splenic flexure is required (see Chapter 7). An effort is made to not divide any mesentery at this stage, as it may devascularize the anastomosis.
anvil into the pelvis (Fig. 10.1). If it lies spontaneously, there will be no anastomotic tension. If the colon keeps falling back into the upper abdomen, then further mobilization of the splenic flexure is required (see Chapter 7). An effort is made to not divide any mesentery at this stage, as it may devascularize the anastomosis.
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