Digestive tract

Anastomoses are used to reconnect bowel after resection of a segment or to bypass a diseased portion. It was shown by Lembert that if the serous (visceral peritoneal) coats of bowel are apposed, they fuse and seal the junction. From this developed the convention of inverting bowel ends when they are united with a seromuscular stitch. The important stitch holding the bowel is an all-coats stitch which picks up the strong, collagenous submucosal layer (Fig. 6.11). Conventionally, the anastomosis is performed in four successive layers. The bowel ends are apposed and their back layers united with a continuous seromuscular suture of metric 3 or 2 (2/0 or 3/0) size synthetic absorbable thread. The back layers are united a second time, either as a continuous or interrupted stitch. This is then continued onto the front wall to complete the union. Finally, the seromuscular stitch on the back wall is continued onto the front wall as an inverting suture to complete the encircling and inverting anastomosis.

It has been shown that single layer can be as safe as two layer anastomoses. Edge-to-edge union is also safe; in theory,

Serous coat Muscularis

Submucosa Mucosa

Figure 6.11. Lembert's inverting seromuscular stitch (above) and all-coats intestinal stitch (below).

Serous coat Muscularis

Submucosa Mucosa

Figure 6.11. Lembert's inverting seromuscular stitch (above) and all-coats intestinal stitch (below).

Figure 6.12. Triangulation method of performing vascular anastomosis.

bringing together the layers that will unite seems sensible. Finally, many surgeons exclude the mucosa from the traditional all-coats stitch. The technique that can best be applied to all gastrointestinal anastomoses is a single layer of extramucosal interrupted sutures of synthetic absorbable thread, with edge-to-edge union.

Mechanical circular stapling devices have been developed that insert a double row of titanium staples across the inverted edges of the two pieces of bowel that are to be united, and then cuts off any excess bowel edges. They produce a conventional inverted anastomosis.

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