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