INTESTINAL ANASTOMOSIS

· In fig 1, it is shown that placement of both anterior and posterior sutures along the original axis is extremely easy and precise if 180 degree rotation of the axis is possible.

· However, close study of figure 1 also reveals two places where sutures cannot be easily or accurately placed, since these two points are not along the axis, as all others are, but are at each end of this first or primary suture line axis.

· To place sutures precisely at these two points, the axis must be reversed 90 degrees as the dotted lines show, so that the two ends of each original suture line axis will be in the center of the new or secondary suture line axis.

· This is a vital concept and is accomplished by using as secondary traction sutures those two permanent sutures midway along the anterior and posterior suture lines, as in the second Open End-To-End procedure and in both closed methods.

· This step is not essential in the standard open end-to end procedure.

· Above, clamps are placed parallel to mesenteric plane with easy 180 degrees rotation of primary suture line axis.

· Placement of anterior and posterior rows is simple.

· Ends of primary suture line axis is created, which brings these two points to the center of the new suture lines axis.

· Below, clamps are placed at right angles to mesenteric plane, complete 180 degrees rotation is not possible, but the development of a secondary suture line axis allows accurate placement of the end sutures.

· The posterior row in the standard open method is easily placed, but in the closed method, a different technique is required.

· A needle is passed over a clamp as compared with over a basting suture in a closed anastomosis.

· While the bite is the same depth and the needle at the same angle.

· In both, note that the point exits freely over the basting suture but impinges against the clamp.

· A cut-away drawing of figure 5 shows greater risk of picking up the posterior wall when using the clamp and the need for a deeper bite with the clamp than with the basting suture.

· Another view shows how the needle placement can tend to pull or push the intestine out of the clamp in a closed anastomosis.

· This is not so with a basting suture.

· Completed closed anastomosis.

· The two colours indicate anterior and posterior row.

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STANDARD OPEN END-TO-END ANASTOMOSIS

· First traction suture is passed below the end of the clamp.

· Ends of segments are carefully lined up with traction sutures and approximated as exactly as possible.

· First Halsted suture is started.

· It should enter about ¼ inch down from traction suture and about ¼ inch to 3/8 inch from cut edge.

· Precise placement of this entire suture is essential, as all the other Halsted sutures on this side must line-up with it as perfectly as possible.

· Needle enters intestine at a right angle, all the way into the lumen, and the needle exits parallel to long axis of intestine, about 1/16 inch from cut edge through full thickness of the intestinal wall.

· The suture is carried across to the other edge in a straight line with its first points of entrance and exit and enters the second intestinal end perpendicular to the intestine as before, and the same distance from the edge as it exited on the other side.

· It exits through the intestinal wall, this exit point being in a straight line with all the other points of entrance and exit, and should be the same distance from the edge as the original entrance point was from the other edge.

· The first half of the first Halsted suture is completed, the second has been started.

· First Halsted suture is completed.

· Note careful lining-up of all points of entrance and exit, in both horizontal and vertical directions.

· All other Halsted sutures must line-up with this one.

· All Halsted sutures are tied and cut, except for the center one which is left long and tagged.

· This is one of the secondary traction sutures.

· By changing the direction of primary traction sutures, as shown, the anastomosis is rotated 180 degrees for placement of the posterior of sutures.

· Halsted sutures are placed exactly as was done on the anterior row, with the same precision.

· Placement of center Halsted suture is shown.

· All posterior Halsted sutures have been placed, tied, and cut, again leaving the center one long and tagged.

· This is the other secondary traction suture.

· The primary traction sutures are removed.

· The primary suture line axis is reversed 90 degrees by traction on the secondary traction sutures, the secondary suture line axis is established.

· This puts the antimesenteric end of the primary axis in the center of the secondary axis, and a Halsted suture is easily and accurately placed, red arrow.

· The direction of the secondary traction sutures again is reversed and traction applied.

· The mesenteric end of the primary suture line axis, red arrow, is in the center of the new secondary axis, making closure easy.

· Special care must be taken in this area, as this is where any suture line is most apt to leak.

· The anastomosis is complete.

· Only one Lembert suture is shown, but there is usually one between each pair of Halsted sutures.

· The mesenteric defect is not closed in the illustration.

· Clamps applied in the mesenteric plane- illustration shows small intestine.

· Dotted line indicates lines of mesenteric section.

· Diseased segment has been removed, basting sutures have been placed just beneath each clamp, as close to clamp as possible.

· Ends of basting sutures are cut about 1.5 inches long.

· The anastomotic sites on mesenteric sides are carefully cleared for about 3/8 to ½ inch.

· Having cleared the mesenteric edge- anastomotic sites, four traction sutures are carefully placed.

· First Halsted suture is applied.

· For purposes of clear detail, the ends of the intestinal segment are shown somewhat separated

· The eight points of exit and entrance of this suture again should line-up vertically and horizontally, as all the other Halsted sutures must line-up with it.

· All the Halsted sutures are placed before tying any.

· This assures a more exact placement.

· All Halsted sutures have been placed, tied, and cut, except for leaving the center one long, which will be one of the secondary traction sutures.

· The primary traction sutures are reversed as indicated.

· The reversal 180 degrees of the primary suture line axis presents the posterior surface.

· The basting sutures are in place and the bracket indicates the space- about ¼ inch- between the primary traction suture and the start of the first posterior Halsted suture.

· All posterior row Halsted sutures have been placed, tied, and cut, again the center one being left long for a secondary traction suture.

· While maintaining traction on the primary, red, traction sutures, the basting sutures are removed.

· Little leakage, if any, occurs with this step.

· After the basting sutures are removed, the primary traction sutures are removed, and traction is applied to the secondary traction sutures.

· This step reverses the suture line 90 degrees; puts the two weak spots, ends of primary suture line axis, in center of new secondary axis; and pulls the original anterior and posterior walls widely apart, absolutely assuring a completely open anastomosis.

· The secondary axis is reversed by the changing direction of the secondary traction sutures.

· The other weak spot, the mesenteric end of primary suture line axis is in center of new or secondary axis and is easily closed.

· Again special care is used in this area.

· Clamps are applied at right angles to the mesentery, and this is the primary suture line axis,

· The mesenteric anastomotic areas are cleared.

· In the diagram, the long mesenteric incision is omitted.

· Four separate traction sutures are placed, and those farthest from the surgeon are grasped in a clamp about 1 inch from the crushing clamps end.

· The other two on the surgeon’s side are spread apart, and traction is applied to these three points.

· The intestinal ends should be carefully lined up, so that the corners are even.

· This creates an inverted V, with the apex of the V pointing away from the surgeon.

· The crushing clamps are removed.

· The distally placed traction sutures are cut fairly close to the holding clamp for convenience, and the posterior row is ready for placement.

· The remaining posterior Halsted sutures are placed, tied, and cut, the center one being left long to serve as a secondary traction suture.

· All points of entrance and exit that are near the basting suture should be as close to the basting suture line as possible.

· This assures a minimal septum formation.

· The posterior row is completed close to the traction sutures.

· After completing the posterior row, the ends of the intestine are laid down perfectly flat and butted against each other.

· The first Halsted suture of the anterior row is placed.

· The bracket indicates distance between primary traction suture and start of first Halsted suture.

· Black arrows indicate weak spots at each end of the primary suture line axis for later closure.

· All anterior row Halsted sutures have been placed, tied, and cut, again the center one being left long for a secondary traction suture.

· In this anterior row, all Halsted sutures are placed before tying any, but this cannot be done on the posterior row.

· The basting sutures are removed.

· Traction is made on the secondary traction sutures, establishing the new secondary suture line axis, pulling the lumen of the anastomosis wide open, placing the two weak spots in the center of the new suture line axis, making their closure easy.

· One spot is being closed, black arrow, and the direction of the secondary traction sutures is reversed as shown, so that the other one is exposed for closure.

· Full rotation is not accomplished but enough is attained so that a complete view of the suture line between the two traction sutures is obtained on both sides.

· The second weak spot is closed with a Halsted suture, and by placing traction on the traction sutures, Lembert sutures can be placed between the Halsted sutures all the way around.

· By reversing the traction suture back and forth, the entire anastomotic suture line is exposed.

· The great superiority of placing the Halsted sutures over the basting sutures rather than clamps is easily appreciated in this situation.