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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 disease, with short bowel syndrome or after pelvic radiation therapy.

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.

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

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. Using the corner sutures, the anastomosis is sewn with a running seromuscular suturing: all intestinal wall layers except the lamina epithelialis mucosae are grasped [fig.~\ref{darmwand}]. After the half circumference, the small bowel has to be turned with the help the corner sutures and the remaining defect is closed with a running suture using the second corner suture. Alternatively, the seromuscular bowel anastomosis can be done in an interrupted suturing technique (Kremer u.a., 1992).

Technique of a hand-sewn bowel anastomosis.

Postoperative Care

General measures:

• Early mobilization
• Intensive respiratory therapy
• Thrombosis prophylaxis
• Laboratory tests
• Wound checks

Analgesia:

Analgesics with a combination of NSAIDs and opioids. A peridural anesthesia facilitates postoperative pain management and minimizes the need for opioids.

Oral Diet after Small Bowel Anastomosis

• Remove of the nasogastric tube after surgery
• Allow small sips of clear liquids the first day
• Increase amounts of clear liquids and allow yoghurt or pudding on postoperative day 1 and 2
• If the patients feels well, allow small amounts of solid food (appetite driven) starting postoperative day 3

Complications of Bowel Anastomosis

• Intraabdominal abscess, wound infection
• Anastomotic insufficiency with peritonitis
• Postoperative paralytic ileus
• Anastomotic stenosis and mechanical ileus
• Small bowel fistula or intraabdominal abscess

References

  Deutsche Version: Muster