Intra-abdominal Anastomotic Techniques

ABSTRACT

Volumes have been written describing numerous methods for joining together two segments of intestine. The specific technique favored by an individual surgeon depends more on training, personal experience, and perhaps blind faith than on results from randomized, prospective controlled studies. The fact is no one particular intestinal anastomotic technique has proven scientifically to be superior. It appears that, if general principles are followed, any technique of joining two segments of intestine together should in most instances result in uncomplicated healing. The objective of this review is not to describe in detail individual anastomotic techniques for which references are provided. Rather, the objectives are threefold: (1) to review the basic principles of intestinal anastomosis, (2) to explore the operative decisions a surgeon makes faced with numerous anastomotic options, and (3) to summarize the complications of intestinal anastomosis. Anastomotic choices discussed in the second objective include the decision to perform an anastomosis, impact of bowel preparation, mechanical or sutured techniques, and adjuncts to anastomoses.

KEYWORD

Intestinal anastomosis - anastomotic leak - anastomotic technique - complications of anastomosis - principles of anastomosis

REFERENCES

• 1 Keighley M RB, Williams N S. Surgery of the Anus, Rectum and Colon, 3rd ed. London: WB Saunders 1999
• 2 Sabiston D C, Lyerly H K. Textbook of Surgery, 15th ed. Philadelphia: WB Saunders 1997: 356
• 3 Garcia J G, Garcia Criado J F, Benito Persona A M, Alonso A G. Healing of colonic ischemic anastomoses in the rat.  Dis Colon Rectum . 1998;  41 892-895
• 4 Irvin T T, Goliger J C. Etiology of disruption of intestinal anastomosis.  Br J Surg . 1973;  60 461-464
• 5 Schrock T R, Deveney C W, Dunphy J E. Factors contributing to leakage of colonic anastomoses.  Ann Surg . 1973;  177 513-518
• 6 Khoury G A, Waxman B P. Large bowel anastomosis, the healing process and sutured anastomosis: a review.  Br J Surg . 1983;  70 61-63
• 7 Torralba J A, Robles R, Parrilla P. Subtotal colectomy versus intra-operative colonic irrigation in the management of obstructed left colon carcinoma.  Dis Colon Rectum . 1998;  41 18-22
• 8 Hsu T-C. One-stage resection and anastomosis for acute obstruction of the left colon.  Dis Colon Rectum . 1998;  41 28-32
• 9 Pahlman L, Glimelius B. Pre or post-operative radiotherapy in rectal and rectosigmoid carcinoma.  Ann Surg . 1990;  211 187-195
• 10 Weiber S, Jiborn H, Zederfeldt B. Pre-operative irradiation and colonic healing.  Eur J Surg . 1994;  160 47-51
• 11 Rabau M, Eyal A, Kluger Y, Dayan D. Bursting pressure in anastomotic healing in experimentally induced colitis in rats.  Dis Colon Rectum . 1998;  41 468-472
• 12 Yamamoto T, Bain I M, Allen R N, Keighley M RB. An audit of sticturoplasty for small-bowel Chron's disease.  Dis Colon Rectum . 1999;  42 797-803
• 13 Platell C, Hall J. What is the role of mechanical bowel preparation in patients undergoing colorectal surgery?.  Dis Colon Rectum . 1998;  41 875-883
• 14 Miettinen R PJ, Laitinen S T, Makela J T, Paakkonen M E. Bowel preparation with oral polyethylene glycol electrolyte solution versus no preparation in elective open colorectal surgery: prospective, randomized study.  Dis Colon Rectum . 2000;  43 669-677
• 15 Kressner U, Antonsson J, Ejerblad S. Intraoperative colonic lavage and primary anastomosis-an alternative to Hartmann procedure in emergency surgery of the left colon.  Eur J Surg . 1994;  160 287-292
• 16 Forloni B, Reduzzi R, Paludetti A. Intraoperative colonic lavage in emergency surgical treatment of left-sided colonic obstruction.  Dis Colon Rectum . 1998;  41 23-27
• 17 Graffner H, Andersson L, Lowenhielm P, Walther B. The healing process of anastomoses of the colon: a comparative study using single, double-layer or stapled anastomosis.  Dis Colon Rectum . 1984;  27 767-771
• 18 Fingerhut A, Hay J M, Elhadad A. Supraperitoneal colorectal anastomoses: hand-sewn versus circular stapler-a controlled clinical trial.  Surgery . 1995;  118 479-485
• 19 Wheeless C R, Smith J J. A comparison of the flow of iodine 125 through three different intestinal anastomoses: standard, Gambee, and stapler.  Obstet Gynecol . 1983;  62 513-518
• 20 McGinn S P, Gartell P C, Clifford P C, Brunton F J. Staples or sutures for low colorectal anastomoses: a prospective randomized trial.  Br J Surg . 1985;  72 603-605
• 21 MacRae H M, McLeod R S. Hand-sewn versus stapled anastomoses in colon and rectal surgery: a meta-analysis.  Dis Colon Rectum . 1998;  41 180-189
• 22 Gambee L P, Jarnjobst W, Hardwick L E. Ten year's experience with a single-layer anastomosis in colon surgery.  Am J Surg . 1956;  92 222-226
• 23 Max E, Sweeney W B, Bailey H R. Results of 1000 single-layer continuous polypropylene intestinal anastomoses.  Am J Surg . 1991;  162 461-467
• 24 Law W L, Bailey H R, Max E. Single-layer continuous colon and rectal anastomosis using monofilament absorbable suture (Maxon℗): a study of 500 cases.  Dis Colon Rectum . 1999;  42 736-740
• 25 Bell R H, Rikkers L F, Mulholland M W. Digestive Tract Surgery: A Text and Atlas.  Philadelphia: Lippincott-Raven 1996: 1472-1494
• 26 Zollinger R M, Zollinger R M. Atlas of Surgical Operations. McGraw-Hill; 1993: 16-172
• 27 Ravitch M M, Steichen F M. A stapling instrument for end-to-end inverting anastomoses in the gastrointestinal tract.  Ann Surg . 1979;  189 791-797
• 27a Beck D E. Intraoperative Anastomotic Complications. In: Hicks TC, Beck DE, Timmcke AE, Opelka FG, eds. Complications in Colorectal Surgery Baltimore: Williams & Wilkins 1996: 70-81
• 27b Last M D, Fazio V W. The rational use of the purse-string device in constructing anastomosis with the circular stapler.  Dis Colon Rectum . 1985;  28 979-980
• 27c Khoury D A, Opelka F G. Anoscopic-insertion of end-to-end anastomosimg staplers.  Dis Colon Rectum . 1995;  38 553-554
• 28 Roumen R H, Rahufen F TG, Wignen M W A H, Croiset Van Uchelen F A M A. ``Dog ear'' formation after double stapled low anterior resection as a risk for anastomotic disruption.  Dis Colon Rectum . 2000;  43 522-525
• 29 Moritz E, Achleitner D, Holbling N. Single versus double stapling technique in colorectal surgery: a prospective, randomized trial.  Dis Colon Rectum . 1991;  34 495-497
• 30 Detry R J, Kartheuser A, Delriviere L. Use of the circular stapler in 1000 consecutive colorectal anastomoses: experience of one surgical team.  Surgery . 1995;  117 140-145
• 31 Beard J D, Nicholson M L, Sayers R D. Intraoperative air testing of colorectal anastomoses: a prospective, randomized trial.  Br J Surg . 1990;  77 1095-1097
• 32 Ho Y H, Tan M, Leong A. Anal pressures impaired by stapler insertion during colorectal anastomosis: a randomized, controlled trial.  Dis Colon Rectum . 1999;  42 89-95
• 33 Wagensteen O H, Wagensteen S D. The Rise of Surgery: From Empiric Craft to Scientific Discipline.  Minneapolis: University of Minnesota Press 1978: 120
• 34 Bubrick M P, Corman M L, Cahill C J. Prospective, randomized trial of the biofragmentable anastomosis ring.  Am J Surg . 1991;  161 136-143
• 35 DiCastro A, Biancari F, Brocato R. Intestinal anastomosis with the biofragmentable anastomosis ring.  Am J Surg . 1998;  176 472-474
• 36 Choi H J, Kim H H, Jung G J, Kim S S. Intestinal anastomosis by use of the biofragmentable anastomotic ring: is it safe and efficacious in emergency operations as well?.  Dis Colon Rectum . 1998;  41 1281-1286
• 37 Bailey R W, Flowers J L. Complications of Laparoscopic Surgery.  St. Louis: Quality Medical Publishing 1995: 278-279
• 38 Thaler K, Schoenleben F, Scheiddach H. Laparoscopic-assisted colon anastomosis using the Valtrac ring: an animal study.  Dis Colon Rectum . 1999;  42 1196-1199
• 39 Carter D C, Jankins D HR, Whitfield H N. Omental reinforcement of intestinal anastomoses.  Br J Surg . 1972;  59 10
• 40 McLachlin A D, Denton D W. Omental protection of intestinal anastomoses.  Am J Surg . 1973;  125 134
• 41 Trowbridge P R, Howes E L. Reinforcement of colon anastomoses using polyurethane foam treated with neomycin: an experiemental study.  Am J Surg . 1967;  113 236
• 42 Laufman H, Method H. Effects of absorbable foreign substance on bowel anastomosis.  Surg Gynecol Obstet . 1948;  86 669
• 43 Hoffmann J, Shokouh-Amiri M H, Damm P, Jensen R. A prospective, controlled study of prophylactic drainage after colonic anastomoses.  Dis Colon Rectum . 1987;  30 449-452
• 44 Sagar P M, Couse N, Kerin M. Randomized trial of drainage of colorectal anastomoses.  Br J Surg . 1993;  80 769-771
• 45 Pakkastie T E, Luukkonen P E, Jarvinen H J. Anastomotic leakage after anterior resection of the rectum.  Eur J Surg . 1994;  160 293-297
• 46 Ravo B, Ger R. A preliminary report on the intracolonic bypass as an alternative to temporary colostomy.  Surg Gynecol Obstet . 1984;  159 541-545
• 47 Ravo B, Mishrick A, Addei K. The treatment of perforated diverticulitis by one-stage intracolonic bypass procedure.  Surgery . 1987;  102 771-776
• 48 Vignali A, Fazio V W, Lavery I C. Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients.  J Am Coll Surg . 1997;  185 105-113
• 49 Luchtefeld M A, Milsom J W, Senagore A. Colorectal anastomotic stenosis: results of a survey of the ASCRS membership.  Dis Colon Rectum . 1989;  32 733-736