DISCUSS TECHNIQUE OF

COLORECTAL
ANASTOMOSIS
GASTROINTESTINAL SURGERY
UNIT
DEPARTMENT OF SURGERY
ABUTH ZARIA

OUTLINE

Introduction
Colorectal anastomotic healing
Technique of colorectal anastomosis
Preoperative
Intraoperative
Open/ / laparoscopic
Hand sewn
Staple
Sutureless anastomosis
Postoperative
Complications/Anastomotic failure
Conclusion

INTRODUCTION
Connecting sections of the intestine after the surgical
removal of a diseased portion safely has been the
subject of research and invention since the 19th
century.
understanding of how the bowel heals and how to
perform intestinal anastomoses safely and effectively
has improved considerably.
Improved outcome is attributable to improved
anesthesia, more potent antibiotics, better
postoperative monitoring & care and SURGICAL
TECHNIQUE.

Definition

Surgically created connection between

the colon and rectum

Blood supply

BLOOD SUPPLY

HEALING IN COLORECTAL
ANASTOMOSIS
Most of the strength of the bowel wall resides
in the submucosa
serosa (i.e., the visceral peritoneum) holds
sutures better than either the longitudinal or
the circular muscle layer . The absence of a
peritoneal layer makes suturing of the rectum
below the peritoneal reflection technically
more difficult than suturing the intraperitoneal
segment.
Poor blood supply

Healing in colorectal anastomosis

The process of intestinal anastomotic
healing mimics that of wound healing
elsewhere in the body
The environment for wound healing;
Presence of shear stress (secondary to
intraluminal bulk transit and peristalsis).
Presence of aerobic and anaerobic
bacteria.

Healing in colorectal anastomosis

Lag phase (Day 0-4)
Acute inflammatory response

Fibroplasia phase (Day 3-14)

Fibroplasts proliferation
Immature collage is laid down

Maturation phase (> Day 10)

Collage is remodeled
Strength of anastomosis is increased

TECHNIQUE OF COLORECTAL
ANASTOMOSIS
PREOPERATIVE

INTRAOPERATIVE

POSTOPERATIVE

Indications for colorectal anastomosis

Bowel gangrene: mesenteric vascular disease, prolonged
intestinal obstruction, intussusceptions, or volvulus
Malignancy
Benign conditions, such as intestinal polyps,
intussusception, or roundworm infestation with intestinal
obstruction
Infections, such as tuberculosis complicated with
stricture or perforation
Traumatic perforations
Large perforation (traumatic) not amenable to primary
closure
Radiation enteritis complicated with bleeding, stricture,
or perforation

Contraindications
Severe sepsis
Poor nutritional status like severe
hypoalbuminemia
Disseminated malignancy (multiple
peritoneal and serosal deposits, ascites)
Viability of bowel in doubt
Fecal contamination or frank peritonitis
An unhealthy bowel condition precludes
primary anastomosis.

PREOPERATIVE
Hydration
Malnutrition
Weight reduction
Smoking
Control of
comorbidities:
Diabetics, HTN

Antibiotic
prophylaxis
DVT prophylaxis
Bowel
preparation
Indwelling
urethral catheter
Nasogastric tube

INTRAOPERATIVE

ANAESTHESIA
PATIENT POSITIONING
INCISION
EXPOSURE
BOWEL RESECTION
Early vascular control
Mobilization
Division of the mesentery (marginal artery of
drummond)
Division of the bowel

FASHIONING OF ANASTOMOSIS

Principles of division of
mesentery
Transillumination to identify
mesenteric blood vessels
Isolation of vessels by dividing
surrounding fat
Division between clamps
Ligating with suitable sutures to
prevent knot slippage
preservation of vascular arcade to
the bowel ends

Principles of division of the

bowel
noncrushing clamp on the bowel end
used for anastomosis and crushing
clamps on the bowel to be resected .
Clamps are applied from the
antimesenteric end.
bowel is divided using a knife close
to the crushing clamp.
direction of division is oblique

GENERAL PRINCIPLES
Good blood supply at bowel ends
Proper approximation of bowel ends
Absence of Tension & distal
obstruction
Gentle tissue handling
Closure of mesenteric defect
Meticulous surgical technique

Suture material
IDEAL: causes minimal inflammation and
tissue reaction, while providing maximum
strength during the lag phase of wound
healing.
Popular choices include:
Absorbable (vicryl, PDS) vs. non absorbable
(silk).
Monofilament (PDS, Maxon) vs. braided
(vicryl)

Suture format

Size of suture bites

In-between Distance of Bite
Suture Tension
Configuration of the Bite
Inverting vs Everting Sutures

HAND SEWN
ANASTOMOSIS

DOUBLE LAYERED COLORECTAL

ANASTOMOSES

Alignment of bowel ends

Seromuscular stay sutures.
Posterior interrupted lembert layer
Inner posterior layer
Inner anterior layer
Anterior interrupted lembert layer

SINGLE LAYERED COLORECTAL

ANASTOMOSIS
HALSTEAD
one layer of interrupted or
continuous absorbable sutures.
Advantage:
take significantly less time to construct
Less interference with blood flow
less costly

Inverting vs everting edges

Everting anastomoses:
more adhesions
less stenosis
Anastomotic leak

Interrupted vs continious
suturing
Interrupted:
More technical.
Time-consuming.

Continious:
better serosal apposition.
Adequacy of blood flow.

Configuration of colorectal
anastomosis
End to End
Side to End

STAPLE COLORECTAL
ANASTOMOSIS

End to end staple

anastomosis
Curcumferentially clear fat at intended areas of
bowel division.
Either place automatic pursestring across
proximal part of colon with straight bowel
clamp just distal and divide colon sharply
or
B) use GIA stapler to divide colon, excise
proximal
staple line, and place handsewn pursestring.

STAPLE ETE GIA

Use Allis clamps to grasp edges of colotom

for anastomotic sizing.
Place chosen anvil into lumen and tie
pursestring.
Place TA stapler across the point chosen fo
division
of the rectum.
Place angled clamps proximally for bowel
control.
Fire TA stapler and sharply divide rectum.

 Advance spike completely.

For handsewn purse string, excise TA
staple line.
Place handsewn purse string at
divided edge of rectum.
Have assistant pass circular stapler
per rectum.

 Tie purse string around spike shaft.

Advance spike completely.
Place anvil on spike, close stapler,
and fire.
Partially open stapler, gently
disengage from
anastomosis and remove.
Inspect donuts for completeness

SUTURELESS COLORECTAL
ANASTOMOSIS
Compression
anastomosis
Murphys button (1892)
The idea was to compress
two bowel walls together
and cause a simultaneous
necrosis and healing
process leading to the
joining of the two lumens.
Valtrac BAR, AKA-2,
Compression anastomotic
clip, Magnamosis

Recent advances
Doxycycline coated sutures
Electric Welding of soft tissues
Robotic colorectal anastomosis

Complications of colorectal
anastomosis
Anastomotic leak
Bleeding
Wound infection
Anastomotic stricture
Prolonged functional ileus, especially in
children

Determinants of anastomotic
failure
Intrinsic factors
Hypotension,
hypoxia
Jaundice, uraemia
Malnutrition,
immunocompromise
Steroid, cytotoxic
drugs
Previous irradiation
Peri-anastomosis
sepsis, haematoma
Distal obstruction

Surgical
techniques
Blood supply
Appropriate
alignment
No tension
Maintenance of
apposition

DETERMINANT OF ANASTOMOTIC
FAILURE

Age.
Anemia.
Radiation Therapy.
Schedule.
Infection.
Intraoperative
Hypotension.
Intraoperative
Transfusion.
Duration of Operation.

Peritoneal Level.
Segment.
Carcinoma at Margins.
Disease.
Experience of
Surgeon.
Technic of
Anastomosis.
Proximal
Decompression.

Testing the anastomosis

The integrity of the anastomosis can

be checked by filling the pelvis with
saline and instilling air through the
anus to look for any air bubbles.

CONCLUSION
Much of the morbidity and approximately one third of
deaths following colorectal surgery result from
anastomotic leak.
The central importance of meticulous technique means
that constant practice and careful attention to detail are
essential for all surgeons operating on the GI tract.
RESEARCH:
best suture material or stapler for specific operations
the most suitable and best-tolerated type of bowel preparation
the mechanisms and variables involved in wound healing and
collagen deposition
Importance of local and systemic factors in determining overall
outcome

REFERENCE
ACS Surgery
Farquharson textbook of operative general
surgery
Systematic Review of the Technique of
Colorectal Anastomosis: JAMA Surg.
2013;148(2):190-201
Techniques for colorectal anastomosis:World J
Gastroenterol. 2010 April 7; 16(13): 16101621.
Factors Contributing to Leakage of Colonic
Anastomoses:Ann. Surg. May 1973