How to do and how not to do

1. Bowel Anastomosis
Evolution of the technique
and the modern practise
Dr Mohan Samarasinghe
Consultant Surgeon in Gastroenterology

2. stomo sisAna
Without Opening/Mouth Status
2

3. Prior to the nineteenth century, intestinal
surgery was limited to exteriorisation
3

4. Systematic studies on intestinal suturing really
began in the early nineteenth century. In 1812,
Travers studied the healing of hand sewn
anastomoses in rabbits.
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5. Attempts at closing a bowel opening
• Glover's Suture - Mucosa to mucosa continuous - ends brought through
the anterior abdominal wall, removed later
• Ledran's Suture - Mucosa to mucosa, tied multiple sutures on the same
side and twisted both suture ends together to pucker up the wound
• Bertrandi's suture - The lips of the wound being approximated with
continuous suture. no invagination
• Jobert’s suture - Interrupted sutures to intussuscepted the proximal end
to distal end
• Ramdohr's lnvagination - Invagination of the two ends by stitching them
together by two or three points of the interrupted suture
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6. Glover's Suture
Mucosa to mucosa continuous - ends brought through
the anterior abdominal wall, removed later
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7. Ledran's Suture
Mucosa to mucosa, tied multiple sutures on the
same side and twisted both suture ends
together to pucker up the wound
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8. Bertrandi's suture
The lips of the wound being approximated with
continuous suture. no invagination
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9. Jobert’s suture
Interrupted sutures to intussuscepted the
proximal end to distal end
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10. Ramdohr's lnvagination
Invagination of the two ends by stitching them together by
two or three points of the interrupted suture
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11. Antoine Lembert (1802–1851)
Antoine Thomas Alfred Étienne
Lembert , 1802–1851, Surgeon at
Hôtel Dieu, Paris, France.
Study on intestinal suture
with a description of a
new procedure for
performing this surgical
operation
Lembert A. Repertoire general
d'anatomie et de physiologie
pathologique et des cliniques
chirurgicales. Vol. 2. 1826:100-7
11

12. Lembert Suture
• He noted that the muco-mucosal sutures are of poor
quality and should be abandoned in favor of
sero-serous sutures.
• The originality of Lembert is to make a musculo-serous
interrupted suture with separate points with leaning of
the serous surfaces and inversion of the edges of the
wound in the intestinal lumen.
• This suture is sometimes called far-near-near-far
depending on the point of penetration of the needle
relative to the edge of the wound. ? vertical mattress
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13. Lembert Suture
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14. Lembert's modified by Dupuytren
• Same as the lembert’s suture but made
continuously
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15. Lembert's modified by Jobert
• Sutures traverse the entire thickness of the
bowel wall
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16. Lambert’s modified by Czerny (1881)
• Mucosa united with the first layer and then
overlying Lembert’s stitch
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17. Lumber’s method modified by Kocher
• Same configuration as
Czerny’s modification
• Utilised a two-layer
anastomosis
• First a continuous all-layer
suture using catgut
• Then an inverting continuous
(or interrupted) sero-
muscular layer suture using
silk
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18. Modern day double layer
• Same configuration as
Czerny’s modification of
the Lembert’s suture
• Utilises a two-layer
anastomosis
• Now uses synthetic
sutures with minimal
tissue reactions
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19. Connell (1892)
• Continuous inverting suture
• Horizontal mattress suture
• Cushing modified
it to sero-muscular
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20. William Stewart Halsted (1852 -1922)
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21. Halstead’s plain quilt single
layer
All passes through bowel wall are catching the
submucosa
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22. Halstead’s ➔ Dudley ➔ Matheson
• Halsted’s paper in 1887 emphasised the hitherto overlooked
importance of the submucosa in terms of suture placement
• Dudley in Aberdeen used a single layer technique in 1958 in
ileo-colic anastomosis
• Matheson in 1976 devised a technique described as ‘single-layer
appositional sero-submucosal anastomosis’.
• The theoretical advantages of a single over a two layer are more
rapid and reliable healing because of minimal interference with
vascularity and more accurate apposition of the divided bowel.
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23. Modern Single Layer : Sero-Submucosal
• Anatomical layers
approximation
• Good tissue
holding strength
• Minimal tissue
necrosis
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24. Factors to Consider
• Prevention of spillage - Clamping / decompress
• Avoid clamping or suturing mesenteric vessels
• Good Lighting
• Maintenance of good perfusion and tissue
oxygenation (BP and Sat)
• Assessment of Viability of bowel
• Blood supply- bright red bleeding from cut edge
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25. Negotiating caliber
• Oblique division
• Cheatling
• Side-to-side
• End-to-side
• Closer bites from the narrow
side, wider bites from the
wider side
• Partial closure of the wider
side
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26. Tension Free
Tension causes ischaemia
and structural failure
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27. Appropriate Sutures
• Hydrolysing (Absorbable)
• Non-reacting / inert (Non-absorbable)
• Good knot security
• Some elasticity
Vicryl (Polygalactin 910)
PDS (Polydiaxanone)
Ethibond (Polyester)
Polypropylene
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28. Edges
• Neat (straight sharp cut)
• Haemostasis
• Trim excess mucosa
• Inverting
• Adequate patency
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29. Closure of Mesenteric Defect
• Interrupted
• Absorbable
• Only serosa (Save mesenteric vessels)
• Adequately spaced to prevent creating
multiple small holes in the mesentery
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30. Physiology of bowel healing
• Early phase (0–4days): There is an acute
inflammatory response, but no intrinsic
cohesion.
• Fibroplasia (3–14days): Fibroblast proliferation
occurs with collagen formation.
• Maturation stage (>10 days): This is the period
of collagen remodelling, when the stability and
strength of the anastomosis increase
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31. • Travers B. An inquiry into the process of nature in repairing injuries of the intestines: illustrating the
treatment of penetrating wounds, and strangulated hernia. London: Longman, Hurst, Rees, Orme, and
Brown, 1812.
• Senn N. Enterorrhaphy; its history, technique, and present status. JAMA 1893;21:215–35.
• Lembert A. Nouveau procede d'enterorraphie. Repertoire General d'Anatome et de Physiologie
Pathologique 1826;2:3.
• Lembert A. Nouveau procede d'enterorraphie Arch Gen Med 1827;13:234.
• Czerny. Quoted by Jaffee K. Uber darmresection bei gangranosen hernien. Sammlung Klinischer
Vorträge 1883;201:1689–1702.
• Connell ME. An experimental contribution looking to an improved technique in entorrhaphy, whereby
the number of knots is reduced to two, or even one. Med Rec 1892;42:335–7.
• Halstead WS. Circular suture of the intestine—an experimental study. Am J Med Sci 1887;94:436–61.
• Reid MR. Some considerations of the problems of wound healing. N Engl J Med 1936;215:753.
• Carrel A. The treatment of wounds. JAMA 1910;55:2148–50.
• Howes EL, Sooy JW, Harvey SC. The healing of wounds as determined by their tensile strength. JAMA
1929;92:42–5.
• Matheson NA, Irving AD. Single layer anastomosis in the gastrointestinal tract. Surg Gynecol Obstet
1976; 143: 619-24.
References
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32. Thank you