Enteroenterostomy Stapled

Figure 19-1a Small intestinal resection. A, After abdominal exploration, small bowel exposure is obtained. Because of the mobility that the small bowel mesentery provides, many lesions can be exteriorized. The nondiseased portion of the small bowel should be placed within the intraperitoneal space and covered with moist towels to prevent desiccation. B, The site of resection is selected. A small opening is created immediately adjacent to the bowel wall through the mesentery using a hemostat. Care is taken not to traumatize small blood vessels entering the bowel wall. C, Small blood vessels adjacent to the bowel wall are divided between clamps and controlled with fine ligatures, enlarging the window adjacent to the bowel wall. D, The area of resection is outlined by dividing the peritoneal surface of the mesentery. For benign small intestinal disease, the amount of mesentery that is resected may be minimal. For disease that is suspected or proved to be malignant, a wedge-shaped portion of the small intestinal mesentery, containing drainage of lymphatic vessels, should be included with the specimen. E, Mesenteric vessels are individually controlled with hemostats and ligated with fine suture. F, Completed mesenteric division.

Figure 19-1b G-1, The bowel wall is divided using a scalpel after application of occluding bowel clamps. The clamps are applied to the bowel wall at an angle so that a spatulated anastomosis can be created, enlarging the luminal cross-section of the anastomosis. G-2, Alternatively, a GIA-type stapler can be used to divide the bowel. With this technique, the staple line is left behind and prevents spillage during the anastomosis. H, Seromuscular sutures are placed as "corner" stitches for traction. A nonabsorbable suture, typically No. 3-0 silk, may be used. I, Interrupted No. 3-0 silk seromuscular sutures are placed and tied for completion of the posterior row. Excess tissue is divided using a scalpel placed immediately adjacent to the occluding clamp. J, A full-thickness inner layer of mucosal sutures is next placed. Absorbable suture is used for the mucosal layer. The figure depicts a technique using interrupted sutures. K, The mucosal suture is continued onto the anterior wall.

Figure 19-1b G-1, The bowel wall is divided using a scalpel after application of occluding bowel clamps. The clamps are applied to the bowel wall at an angle so that a spatulated anastomosis can be created, enlarging the luminal cross-section of the anastomosis. G-2, Alternatively, a GIA-type stapler can be used to divide the bowel. With this technique, the staple line is left behind and prevents spillage during the anastomosis. H, Seromuscular sutures are placed as "corner" stitches for traction. A nonabsorbable suture, typically No. 3-0 silk, may be used. I, Interrupted No. 3-0 silk seromuscular sutures are placed and tied for completion of the posterior row. Excess tissue is divided using a scalpel placed immediately adjacent to the occluding clamp. J, A full-thickness inner layer of mucosal sutures is next placed. Absorbable suture is used for the mucosal layer. The figure depicts a technique using interrupted sutures. K, The mucosal suture is continued onto the anterior wall.

Enteroenterostomy

Figure 19-1c L, Completion of the inner mucosal layer of interrupted sutures anteriorly. M, A continuous suture technique may also be used. The absorbable mucosal suture is shown, making the transition from the posterior wall to the anterior wall of the anastomosis. N, A second layer of interrupted seromuscular No. 3-0 silk sutures is used to complete the anterior aspect of the anastomosis. O, If discrepancy in bowel size exists, a side-to-side enteroenterostomy may be preferable. The bowel may be conveniently divided by application of a GIA stapler. The staple line closure may be reinforced, at the discretion of the surgeon, by interrupted No. 3-0 silk sutures. Traction sutures are placed to maintain alignment of the bowel. The illustration depicts an incision being made after application of interrupted No. 3-0 silk seromuscular sutures in the posterior aspect of the anastomosis. The bowel may be opened with a scalpel. Alternatively, cautery may be used to open the bowel if bowel content and gas have been "milked" from the area to reduce the risk of cautery-induced explosion. P, A posterior layer of full-thickness mucosal sutures is placed, using absorbable material. Q, The mucosal suture is continued on the anterior aspect of the anastomosis.

EnteroenterostomyEnteroenterostomy Pictures

Figure 19-1d R, A layer of seromuscular interrupted No. 3-0 silk sutures anteriorly completes the anastomosis. S, The mesenteric defect is reapproximated to prevent internal hernia formation. The mesenteric defect may be closed using a running suture or properly spaced interrupted sutures. T, A bowel resection may also be performed laparoscopically in appropriate patients.1 ' A pneumoperitoneum is achieved, and ports are placed as shown to obtain access to both the upper and lower abdomen. U, The abdomen is explored laparoscopically, and the loop of bowel to be resected is brought through the abdominal wall and exteriorized. The resection can then be performed in the standard fashion. V, An anastomosis is performed extracorporeally and the bowel is then returned to the abdominal cavity and the fascia and wounds closed.

(A-G-1, H-T from Rossi, R.L.: Small bowel resection. In Braasch, J.W., Sedgwick, C.E., Veidenheimer, M.C., et al. [eds.]: Atlas of Abdominal Surgery. Philadelphia, WB Saunders, 1991, with permission; G-2 from Stapling Techniques in General Surgery. Norwalk, CT, United States Surgical Corporation, 1988, p. 91, with permission; U and V from Martin, D.T., Pitcher, D.E., and Zucker, K.A.: Laparoscopic small bowel surgery In Arregui, M.E, Fitzgibbons, R.J., Katkhouda, N., et al. [eds]: Principles of Laparoscopic Surgery. New York, Springer-Verlag, 1995, p. 280, with permission.)

Stapled End Side AnastomosisLaparoscopic Small Bowel ResectionPicture Stapled Colon
Figure 19-2b D, The anastomosis is rotated 120 degrees, and the process is repeated for a portion of the bowel General Surgery. Norwalk, CT, United States Surgical Corporation, 1988, with permission.)

circumference. E, After three applications of the TA stapling device, a complete anastomosis exists. At each end of the triangle, the two staple lines intersect. F, The traction sutures are removed with completion of the anastomosis, and the mesenteric defect is closed. (A to F from Stapling Techniques in

Figure 19-3 Stapled side-to-side anastomosis. A, The opened ends of the small bowel segments to be anastomosed are aligned along their antimesenteric surfaces. Traction sutures are placed to stabilize the bowel ends. A GIA-type stapler is passed into the opened ends, one limb of the stapling device in each segment of bowel. The device is engaged and fired, creating a side-to-side enteroenterostomy along the antimesenteric borders of the two sections of bowel. B, Traction is placed on the two sutures, aligning the opened ends of the small bowel segments. C, A TA-type stapling device is used to approximate and close the two small bowel segments. D, Completed anastomosis. (A-D from Stapling Techniques in General Surgery. Norwalk, CT, United States Surgical Corporation, 1988, pp. 144-145, with permission.)

Figure 19-3 Stapled side-to-side anastomosis. A, The opened ends of the small bowel segments to be anastomosed are aligned along their antimesenteric surfaces. Traction sutures are placed to stabilize the bowel ends. A GIA-type stapler is passed into the opened ends, one limb of the stapling device in each segment of bowel. The device is engaged and fired, creating a side-to-side enteroenterostomy along the antimesenteric borders of the two sections of bowel. B, Traction is placed on the two sutures, aligning the opened ends of the small bowel segments. C, A TA-type stapling device is used to approximate and close the two small bowel segments. D, Completed anastomosis. (A-D from Stapling Techniques in General Surgery. Norwalk, CT, United States Surgical Corporation, 1988, pp. 144-145, with permission.)

Enteroenterostomy

Figure 19-4a Stapled side-to-side enteroenterostomy. A, A variation of the technique described in Figure 19-3 involves creating an anastomosis before the bowel resection. The loop of bowel to be resected is isolated using a clamp. As depicted in the figure, the small bowel mesentery has been divided previously. The segments of bowel are aligned side to side, and a small opening is made with a scalpel or cautery, on the antimesenteric border. B, A GIA-type stapler is introduced into both limbs of the small intestine. The stapling device is positioned and fired, creating a side-to-side enteroenterostomy. C, A TA-type stapler is used to close the ends of the bowel. The stapling device is positioned such that the enterotomies used to introduced the GIA stapler are excluded. After firing the TA stapler, the bowel segment is resected. D, The completed anastomosis is illustrated.

Figure 19-4a Stapled side-to-side enteroenterostomy. A, A variation of the technique described in Figure 19-3 involves creating an anastomosis before the bowel resection. The loop of bowel to be resected is isolated using a clamp. As depicted in the figure, the small bowel mesentery has been divided previously. The segments of bowel are aligned side to side, and a small opening is made with a scalpel or cautery, on the antimesenteric border. B, A GIA-type stapler is introduced into both limbs of the small intestine. The stapling device is positioned and fired, creating a side-to-side enteroenterostomy. C, A TA-type stapler is used to close the ends of the bowel. The stapling device is positioned such that the enterotomies used to introduced the GIA stapler are excluded. After firing the TA stapler, the bowel segment is resected. D, The completed anastomosis is illustrated.

Staples Tia Bowel Anastomosis Technique

Figure 19-4b E, The GIA stapling device can also be used to create a side-to-side enteroenterostomy. Traction sutures are used to align the two segments of bowel. A small opening is made along the antimesenteric border for introduction of the stapling instrument. F, After appropriately positioning the stapler, the instrument is fired, creating a side-to-side enteroenterostomy along the antimesenteric border. The opening used for introduction of the instrument can be closed with interrupted sutures or by application of a TA-type stapling device. (A-F from Stapling Techniques in General Surgery. Norwalk, CT, United States Surgical Corporation, 1988, pp. 146-149, with permission.)

Pictures Covidien

Figure 19-5a Ileostomy. A, When an ileostomy is a planned or potential portion of a procedure, preoperative preparation should include siting of the ileostomy. The patient should be examined in both the standing and sitting positions. The ileostomy should be placed in the right lower abdomen at the lateral border of the rectus sheath. The site should be marked preoperatively, with care taken not to place it near skin creases, previous incisions or scars, or areas of cutaneous disease. Improper positioning of the ileostomy site will result in poor appliance fit, discomfort, and leakage of intestinal contents. When an ileostomy is planned, a midline incision is preferable. B, An appropriately sized circular skin incision is made. In obese patients, excision of the underlying subcutaneous tissues is often useful in creating the ileostomy tract. The dissection should continue to the level of the anterior rectus sheath. C, An incision is created in the anterior rectus sheath. D, The rectus muscle fibers are separated with a hemostat, exposing the posterior rectus sheath and peritoneum.

Figure 19-5a Ileostomy. A, When an ileostomy is a planned or potential portion of a procedure, preoperative preparation should include siting of the ileostomy. The patient should be examined in both the standing and sitting positions. The ileostomy should be placed in the right lower abdomen at the lateral border of the rectus sheath. The site should be marked preoperatively, with care taken not to place it near skin creases, previous incisions or scars, or areas of cutaneous disease. Improper positioning of the ileostomy site will result in poor appliance fit, discomfort, and leakage of intestinal contents. When an ileostomy is planned, a midline incision is preferable. B, An appropriately sized circular skin incision is made. In obese patients, excision of the underlying subcutaneous tissues is often useful in creating the ileostomy tract. The dissection should continue to the level of the anterior rectus sheath. C, An incision is created in the anterior rectus sheath. D, The rectus muscle fibers are separated with a hemostat, exposing the posterior rectus sheath and peritoneum.

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