Aim: The proximal edge of the enterotomy in a side-to-side anastomosis has been shown to be the site at highest risk of leakage. Several methods have been described to overcome this vulnerability. The technical challenge of intra-corporeal anastomosis (ICA) is to re-create angles between tissues and instruments, similar to those in an open anastomosis. The axis between the suture line and the needle driver is paramount and this angle should be < 45°. Method: The crotch stitch of the enterotomy is difficult because of the narrow space between the loops and the depth of the anastomosis. The usual technique is suturing right-handed, ‘out–in and in–out’, colonic edge first to small bowel. The risk of suture misplacement (e.g. ‘out–in/out–in’ or ‘out–out’) is similar to open procedures but laparoscopically the second bite is challenging, due to the straight needle-driver. This may lead to asymmetrical closure of the corner resulting in a slightly larger angle on the bowel side and a potential postoperative leak/fistula. Rotating the small bowel loop to counterbalance this issue, risks tearing of the staple line. The rationale is that starting with a back-handed stitch and taking the small bowel edge first would allow the necessary acute angled bite to be achieved. Subsequently, mounting the needle right-handed for taking the colonic edge also allows achievement of an acute angled bite. Results: Our novel technique, named the ‘back-handed, left-to-right stitch’ technique, is intended to achieve symmetrical approximation of the ileal and colonic edges during laparoscopy, with an optimal closure of the deepest extremity of the enterotomy. Such a stitch, used in a series of 10 patients, may be useful to avoid leaving an opening within this angle and/or to avoid potential technical pitfalls when closing the deepest apex of the enterotomy. Conclusion: This ‘back-handed, left-to-right’ stitch described here allows a properly angled closure of the proximal edge of the enterotomy and a safe approximation of the corner of the enterotomy in a side-to-side ICA.

A novel technique for enterotomy closure in stapled laparoscopic intracorporeal anastomosis

di Saverio S;
2017-01-01

Abstract

Aim: The proximal edge of the enterotomy in a side-to-side anastomosis has been shown to be the site at highest risk of leakage. Several methods have been described to overcome this vulnerability. The technical challenge of intra-corporeal anastomosis (ICA) is to re-create angles between tissues and instruments, similar to those in an open anastomosis. The axis between the suture line and the needle driver is paramount and this angle should be < 45°. Method: The crotch stitch of the enterotomy is difficult because of the narrow space between the loops and the depth of the anastomosis. The usual technique is suturing right-handed, ‘out–in and in–out’, colonic edge first to small bowel. The risk of suture misplacement (e.g. ‘out–in/out–in’ or ‘out–out’) is similar to open procedures but laparoscopically the second bite is challenging, due to the straight needle-driver. This may lead to asymmetrical closure of the corner resulting in a slightly larger angle on the bowel side and a potential postoperative leak/fistula. Rotating the small bowel loop to counterbalance this issue, risks tearing of the staple line. The rationale is that starting with a back-handed stitch and taking the small bowel edge first would allow the necessary acute angled bite to be achieved. Subsequently, mounting the needle right-handed for taking the colonic edge also allows achievement of an acute angled bite. Results: Our novel technique, named the ‘back-handed, left-to-right stitch’ technique, is intended to achieve symmetrical approximation of the ileal and colonic edges during laparoscopy, with an optimal closure of the deepest extremity of the enterotomy. Such a stitch, used in a series of 10 patients, may be useful to avoid leaving an opening within this angle and/or to avoid potential technical pitfalls when closing the deepest apex of the enterotomy. Conclusion: This ‘back-handed, left-to-right’ stitch described here allows a properly angled closure of the proximal edge of the enterotomy and a safe approximation of the corner of the enterotomy in a side-to-side ICA.
2017
ileo-colic anastomosis; intracorporeal anastomosis; Laparoscopic colorectal surgery; laparoscopic suturing; right colectomy; surgical technique education;
di Saverio, S; Birindelli, A; Segalini, E; Todero, S; Botusan, Ra; Novello, M; Kwan, S; Biondi, A.
File in questo prodotto:
Non ci sono file associati a questo prodotto.

I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.

Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11383/2088146
 Attenzione

Attenzione! I dati visualizzati non sono stati sottoposti a validazione da parte dell'ateneo

Citazioni
  • ???jsp.display-item.citation.pmc??? 2
  • Scopus 7
  • ???jsp.display-item.citation.isi??? 6
social impact