Bowel anastomosis :interrupted & continuous serosubmucosal

Bowel anastomosis :interrupted & continuous serosubmucosal

HAND SUTURED BOWEL ANASTOMOSIS BY SEROSUBMUCOSAL TECHNIQUE  

1.Types

  • INTERRUPTED SEROSUBMUCOSAL SUTURE ( the “gold standard” for intestinal anastomosis).
  • CONTINUOUS SEROSUBMUCOSAL SUTURE.

2.The Basis

Faster and sounder healing when compared to the traditional two layer anastomosis.

CLOSEUP VIEW OF SINGLE SUTURE
 

3.Advantages

  • Accurate tissue apposition.
  • Incorporates submucosa – the strongest layer.
  • Minimises damage to submucosal vascular plexus.
  • Lesser tissue strangulation.
  • Lesser reduction in lumen size.
  • Interrupted suture accomodates luminal discrepencies upto 50% without resorting to an antimesenteric slit. No ‘purse string’ effect even with continuous suture.
  • Minimises risk of implantation of neoplastic cells.
  • Appropriate for both upper and lower GI tract anastomosis. Continuous suture more useful in upper GI anastomoses (biliary, pancreatic).
  • Appropriate for both accessible and inaccessible sites.
  • Continous suture is faster than interrupted suture.

 

INTERRUPTED SEROSUBMUCOSAL ANASTOMOSIS
 

ACCESSIBLE SITES
 
 

 INACCESSIBLE SITES
 
4.Technique

  • Align ends of ‘clean’ bowel with stay sutures.
  • A 3/0 (round bodied needle) braided nylon, polypropelene, polydioxanone, polygalactin or polyglycolic acid suture is passed through the serosubmucosal layer, marking the midpoint, 5mm from the cut edge, through the proximal and distal bowel and tied.
  • ( Entry through serosa -> Exit through submucosa -> Entry through submucosa -> Exit through serosa)
  • Interrupted sutures are inserted on both sides of the midpoint suture at intervals of 5 –6 mm.
  • In accessible sites, the anterior layer is completed, the anastomosis is rotated through 180 degrees and then the posterior layer is sutured.
  • In inaccessible sites, the posterior layer is tackled initially, followed by the anterior layer.

COLORECTAL ANASTOMOSIS BY CONTROL RELEASE SUTURES
 

  • Colorectal anastomosis deep within the pelvis is easier if all stitches are placed, held taut (by clips or special suture holding clamp) and the colon is slid down to the rectum and then tied.
  • Anastomoses are not drained. (A suction drain may be placed in the hollow of the sacrum to prevent haematoma). Testing of anastomosis for leaks by air insufflation is unnecessary.

  CONTINUOUS SEROSUB MUCOSAL ANASTOMOSIS
  

 
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The technique

  • The suture begins passing through the serosubmucosal layer of the distal and proximal bowel. It is tied and held with a 8 –10cm tail by a mosquito clip.
  • ( Entry through serosa -> Exit through submucosa -> Entry through submucosa -> Exit through serosa)
  • Needle is passed under the knot to start on the posterior layer.
  • Stitches are inserted, taking bites 5mm from the cut edge and 5mm apart.
  • Entry through submucosa -> Exit through serosa -> Entry through serosa -> Exit through submucosa)
  • When the corner is passed, the suture direction is continued unchanged. If desired, the direction of suture can be changed after insertion of a single Connell stitch.
  • After completing the anterior layer, the end of the suture is tied to the 8-10cm tail created at the beginning of the anastomosis.
  • The patency of the anastomosis is checked by palpation.
  • Insufflation by air- water to check the integrity of the anastomosis is not necessary.

Uma Krishnaswamy MS, FRCSEd, FAIS, MA
Consultant General Surgeon
Email :[email protected]

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