intestinal anastomosis, bowel anastomosis, small bowel resection,

1. PRINCIPLES OF BOWEL
ANASTOMOSIS
DR BASHIR YUNUS
GENERAL SURGERY UNIT PRESENTATION
15-May-16 bbinyunus2002@gmail.com 1

2. OUTLINE
• INTRODUCTION
• TYPES
• INDICATIONS
• PRE-OPERATIVE PREPARATION
• INTRA-OPERATIVE PRINCIPLES
• POST-OPERATIVE CARE
• COMPLICATIONS
• CONTROVERSIES
• REFERENCES
15-May-16 bbinyunus2002@gmail.com 2

3. 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.
15-May-16 bbinyunus2002@gmail.com 3

4. 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
15-May-16 bbinyunus2002@gmail.com 4

5. 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
15-May-16 bbinyunus2002@gmail.com 5

6. 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
15-May-16 bbinyunus2002@gmail.com 6

7. PRE-OPERATIVE PREPARATION
• Resuscitation
• Optimization; dehydration, anaemia, infection, nutrition
• Bowel preparation (and avoidance of spillage)
• Antibiotic prophylaxis
• DVT prophylaxis
• Counseling
15-May-16 bbinyunus2002@gmail.com 7

8. 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
15-May-16 bbinyunus2002@gmail.com 8

9. • 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
15-May-16 bbinyunus2002@gmail.com 9

10. 15-May-16 bbinyunus2002@gmail.com 10

11. 15-May-16 bbinyunus2002@gmail.com 11

12. 15-May-16 bbinyunus2002@gmail.com 12

13. 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
15-May-16 bbinyunus2002@gmail.com 13

14. 15-May-16 bbinyunus2002@gmail.com 14

15. 15-May-16 bbinyunus2002@gmail.com 15

16. DOUBLE LAYER ANASTOMOSIS
• An inner continuous absorbable
suture, with stitching of all
layers
• An outer, seromuscular,
interrupted nonabsorbable
suture
• Serosa apposition and mucosa
inversion; the inner layer has a
hemostatic effect, but the
mucosa is strangulated
• Connell stitch- continuous
15-May-16 bbinyunus2002@gmail.com 16

17. 15-May-16 bbinyunus2002@gmail.com 17

18. 15-May-16 bbinyunus2002@gmail.com 18

19. 15-May-16 bbinyunus2002@gmail.com 19

20. 15-May-16 bbinyunus2002@gmail.com 20

21. 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).
15-May-16 bbinyunus2002@gmail.com 21

22. 15-May-16 bbinyunus2002@gmail.com 22

23. 15-May-16 bbinyunus2002@gmail.com 23

24. Postoperative care
• Nil per Os about 5days
• N-G tube
• Iv fluid
• Antibiotic
• Analgesics
• PCV, U/Ecr check
15-May-16 bbinyunus2002@gmail.com 24

25. Complications
• Bleeding
• Anastomotic leak
• Wound infection
• Intra-abdominal abscess
• Obstruction
• Stricture
• Prolonged ileus
• Recurrence
15-May-16 bbinyunus2002@gmail.com 25

26. CONTROVERSIES
• Inversion versus eversion
• Abdominal drains
• N-G tube decompression
15-May-16 bbinyunus2002@gmail.com 26

27. • 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
15-May-16 bbinyunus2002@gmail.com 27

28. 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.
15-May-16 bbinyunus2002@gmail.com 28

29. • 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
15-May-16 bbinyunus2002@gmail.com 29

30. 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
15-May-16 bbinyunus2002@gmail.com 30

31. 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
15-May-16 bbinyunus2002@gmail.com 31