This document discusses intestinal anastomosis, which involves creating a connection between intestinal loops or ends. Intestinal anastomosis is commonly performed for elective and emergency cases involving conditions like cancer, infections, or obstructions. The key factors for a successful anastomosis are minimal contamination, good blood supply, and tension-free apposition of the intestinal ends. The document compares hand-sewn and stapled techniques, noting that while staplers are faster, studies have found no difference in outcomes between the two methods. Proper patient factors and surgical technique are more important than the specific method used.

1. Moderator: Dr.Gaurav Kaushal
Consultant, Dept. of Gen. Surgery
Max super speciality Hospital,
Mohali, Punjab
Presenter : Dr. Asif Mian Ansari
DNB resident
Dept. of General Surgery
Max hospital, Mohali

2.  Creation of joint between intestinal loops or ends
 Common for elective & emergency settings
 Successful intestinal anastomosis:
 Minimal fecal contamination
 Well vascularized
 Tension free apposition

3.  Restoration of continuity following resection of bowel:
 Gangrene, perforation, Malignancy, polyps, intussusception,
Radiation enteritis, Infections (TB with stricture), stoma closure
 Bypass of unresectable disease bowel
 Advanced tumor causing luminal obstruction
 Metastatic disease causing obstruction
 Congenital anomalies-
 intestinal atreasia, Hirschsprung disease
 Bilio-pancreatic diversion

4.  Intestinal healing
 Types of anastomosis
 Technical options

5.  Occurs like other tissues
 Hemostasis & Inflammatory phase
 Proliferative phase
 Remodelling & maturing phase

6. POSITIVE FACTORS
 Good nutritional status
 Haemodynamic stability
 Healthy bowel ends and
microvasculature
 Accurate seromuscular apposition
 No distal obstruction
NEGATIVE FACTORS
 Old age
 High-dose steroids
 Anemia
 Uremia
 Poor nutritional status
 Diabetes mellitus
 Smoking & Alcohol abuse
 High risk site of anastomosis (e.g., low
colorectal anastomoses)
 Faecal contamination
 Haematoma formation

7.  End to end
 End to side
 Side to side

8. SUTURE STAPLER

9.  Choice of suture material:
 Foreign material α inflammation α collagenase production α
1/anastomotic strength
 Two-layer fashion  inner absorbable (surgical gut, polyglycolic acid
polygalactin)
 outer non absorbable (silk)
 One layer fashion  non absorbable (silk) or delayed absorbable
(polydioxanone, polyglyconate)
 Methods of Suturing:
 Interrupted & Continuous sutures (quick / watertight / integrity on
one stitch / vascular constriction )

10. 7 RCTs
408 patients in the SGIA group
432 patients in the DGIA group

11.  Common Suture techniques:
 Continuous over-and-over suture
 Lembert’s suture
 Connell suture
 Cushing suture
Lembert’s

12.  Double layer anastomosis
 Posterior outer  lembert’s sutures
 Posterior inner  over-and-over
continuous sutures
 Anterior inner  connell’s sutures
 Anterior outer  lembert’s sutures

13.  Types of anastomotic staplers:
 Linear non-cutting (TA- trasnsverse anastomosis) stapler
 Linear cutting (GIA-gastrointestinal anastomosis) stapler
 Circular (EEA-end-to-end anastomosis) staplers
 “B” shaped stapled
 Stapled height :
 Vascular stapler  1 mm
 Tissue stapler-BLUE  1.5 mm  for esophagus/small or large bowel
 Tissue stapler-GREEN  2 mm  for stomach/rectum

16. End to End
anastomosis
Side to Side
anastomosis
End to Side
anastomosis

17.  9 RCTs
 622  stapled
 611  hand sewn

18.  Anastomotic leak
 Wound infection
 Obstruction
 Stricture

20.  Hand sewn versus stapled anastomosis

27.  Hepaticojejunostomy  single layer,
end to side with 4-0 or 5-0 absorbable
monofilament sutures
 Pancreaticojejunostomy  two layer,
end to side with absorbable
monofilament suture

28.  Intestinal anastomosis is a common surgery
 Anastomotic healing is similar other tissue healing
 Hand sewn anastomosis is not inferior to stapler
 Anastomosis must be tension free, with good blood supply
and minimal fecal contamination
 Two main benefits of stapler anastomosis:
 Takes less time
 Not objective variations – so inexperienced surgeon can safely do