Dr. med. Dirk Manski



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Small Bowel Anastomosis: Surgical Technique

Review literature: Kremer et al, 1992.

Urologic Indications for Small Bowel Anastomosis

In urology, the technique of small bowel anastomosis is needed for various urinary diversions like ileum conduit or neobladder. Less often, small bowel anastomosis is needed for reconstruction of the ureter or for bladder augmentation.

Contraindications

Do not use small bowel in patients with Crohn's disease, with short bowel syndrome or after pelvic external beam radiotherapy.

Surgical Technique of Small Bowel Anastomosis

Preoperative bowel preparation:

Start with a clear liquid diet 48 hours before the planned operation, this leads to an emptying of the small bowel system from solid debris. Permitted are clear soups, plenty of sweet drinks and high-energy tube feedings without fibers. The day before surgery, an enema is used to clean the rectum.

A more intense mechanical bowel preparation is not necessary and should be avoided.

figure small bowel anastomosis using a GIA
Small bowel anastomosis using a GIA stapler.

Division of mesentery

The desired intestinal loop is held against the surgical light to see the vasculature shining through the mesentery. The peritoneum is incised along the desired line on both sides [see figure bowel anastomosis with GIA]. Vessels crossing the peritoneal incision are isolated and ligated. The isolation of the bowel wall from the mesentery should be done very carefully (1 cm length) to ensure adequate blood supply of the bowel ends.

Small bowel anastomosis with GIA:

A GIA is a linear cutting and suturing stapler device. In the first step, the isolated bowel loop is resected using two applications (two magazines) of the GIA stapler. The use of GIA for bowel resection minimizes the faecal spillage of the abdominal cavity. The two bowel ends are juxtaposed in a side-to-side fashion. At the antimesenteric corner of each staple line, a small enterostomy is done, so that the forks of GIA suturing device can be inserted into each lumen of the bowel ends. After assembly of the GIA care should be taken to avoid cutting the bowel wall near the mesentery. After stapling (third magazine), a large lumen between the two bowel ends is created. The remaining opening is closed either using a hand-sewn technique or using a fourth magazine of the stapler [see figure bowel anastomosis with GIA].

Hand-sewn bowel anastomosis

Suitable suture material for small bowel anastomosis is Vicryl or PDS (4-0). At first, the two ends of the bowel ends are brought close together and corner sutures are done at the mesenteric and antimesenteric part of the open bowel ends. The needles are left in place. Using the corner sutures, the anastomosis is sewn continuously in a seromuscular fashion. After the half circumference, the small bowel has to be turned with the help the corner sutures and the second circumference is sewn.

Alternatively, the seromuscular bowel anastomosis can be done in a interrupted suturing technique.


figure hand-sewn bowel anastomosis

Technique of a hand-sewn bowel anastomosis.


Postoperative Care

General measures:

Analgesia:

Analgesics according to the WHO ladder are prescribed, e.g. a combination of metamizol and tramadol. A peridural anesthesia facilitates postoperative pain management and minimizes the need for opioids.

Oral Diet after Small Bowel Anastomosis

Complications of Bowel Anastomosis







Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z





References

Kremer, K.; Lierse, W.; Platzer, W.; Schreiber, H. W. & Weller, S. (ed.)
Chirurgische Operationslehre: Spezielle Anatomie, Indikationen, Technik, Komplikationen
Thieme, 1992, Band 6 Darm.


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