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Surgical Guide: Bowel Anastomosis

This document describes the steps for performing an end-to-end handsewn bowel anastomosis after small bowel resection. The key steps are: 1) inspecting the bowel ends and ensuring they can be approximated without tension, 2) suturing the mesenteric corners with a continuous layer technique from the inside to outside of the bowel, and 3) completing the anterior and posterior closure and repositioning the bowel in the abdomen. Tips are provided for dealing with differences in lumen size and ensuring adequate vascularization and orientation during suturing.

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Teja Laksana Nukana
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158 views2 pages

Surgical Guide: Bowel Anastomosis

This document describes the steps for performing an end-to-end handsewn bowel anastomosis after small bowel resection. The key steps are: 1) inspecting the bowel ends and ensuring they can be approximated without tension, 2) suturing the mesenteric corners with a continuous layer technique from the inside to outside of the bowel, and 3) completing the anterior and posterior closure and repositioning the bowel in the abdomen. Tips are provided for dealing with differences in lumen size and ensuring adequate vascularization and orientation during suturing.

Uploaded by

Teja Laksana Nukana
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Bowel Anastomosis - End-to-End Handsewn

1. Small bowel resection

Substep Structure Actions Specification

1A Bowel Clamp Apply non-crushing clamps to prevent leakage of bowel contents in the abdominal cavity.

Resect Resect the bowel section that needs to be removed.

Inspect Inspect (1) whether the bowel looks well vascularized (2) whether the two ends can be brought
together without tension (3) whether the lumen sizes are comparable.

TIP: Lumen size difference


If the difference in size is too big to correct during suturing you can choose to either go for an
End-to-Side or Side-to-Side anastomosis, or enlarge one end by cutting in an oblique way from
the anti-mesenteric to the mesenteric side until it matches the other lumen.

HAZARD: Vascularisation corners


The arteries enter perpendicular to the bowel. To avoid creating a poorly vascularised corner to
the obliquely cut bowel, make sure the mesenteric side is the “long” side.

Pull Pull the bowel ends out of the abdominal cavity and preferably work on a gauze or small towel.

Approximate Approximate and clean the mesenteric border to make sure that the sutures do not include
mesenteric fat.

TIP: Bowel orientation


Place the ends oriented in such a way that the anti-mesenteric side faces you and you always
suture towards yourself.

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Bowel Anastomosis - End-to-End Handsewn

2. Small bowel anastomosis

Substep Structure Actions Specification

2A Bowel corner mesenteric side Close Suture the first mesenteric corner with a double-armed suture through all layers from inside to
outside and the second stitch with the same needle from outside to inside in the mesenteric
corner of the opposite lumen using a monofilament slow absorbable thread. (Knot the suture
but) do not cut it.

2B Bowel Close Continue suturing the posterior side of the anastomosis with this needle with an
inside-outside-outside-inside technique. Use a continuous one layer technique with small parts
of the mucosa and slightly larger parts of the seromuscular layer. Distance between the stitches
should be around 3- 5 millimeter.

TIP: Bowel turning


If the other corner is reached at the mesenteric side, it is easiest to turn the bowel by turning the
two clamps in such way that allows the surgeon to suture again towards him/her.

2C Bowel corner anti-mesenteric side Close After reaching the anti-mesenteric site of the posterior wall, switch to the other needle and close
the anterior site of the anastomosis from the mesenteric to the anti-mesenteric site. Finalise the
sutures at the anti-mesenteric site with an adequate knot.

TIP: Two layer anastomosing


If a two layer anastomosis is preferred the second layer is usually knotted with parts from the
seromuscular layer only and using monofilament slowly absorbable thread (Lembert sutures).

2D Bowel Reposition Remove the clamps from the bowel and reposition it in the abdomen.

2E Mesentery Close Close the mesentery to prevent herniation and/or rotation of the bowel.

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