Scope of radical surgery for colon tumors. Resection of the transverse colon Resection of the transverse colon

Indications: the presence of a pathological process in the middle sections of the transverse colon: cancer, polyps with malignancy, etc. (Fig. 18 - resection boundaries, diagram).

Rice. 18. Resection of the transverse colon (diagram).

a - boundaries of resection and application of end-to-end ascendodescendoanastomosis for metastases to regional lymph nodes:

b - the boundaries of resection and the imposition of a transverse transversal anastomol end in horses in the absence of metastases:

1 - middle colon artery; 2 - right colon artery; 3 - ileocolic

Rice. 19. Resection transverse colon. Stages of the operation a - cutting the greater omentum with scissors along the avascular zone (with extensive resection, the omentum is removed along with the intestine); 6 - intersection of the gastrocolic ligament with ligation of blood vessels; c - dissection of the mesentery of the transverse colon with ligation of the middle colon artery. The dotted line marks the boundaries of the intersection of the intestine.

Operation: median laparotomy with revision of the abdominal cavity.

When deciding on the resection of the transverse colon, it is advisable to start the operation with the removal of the greater omentum in order to facilitate further manipulations. To do this, the greater omentum is lifted and along the avascular zone near the intestine, it is cut off with scissors from the transverse colon along the entire length from the right to the left bends (Fig. 19, a). Next, the gastrocolic ligament is crossed in parts between the clamps and the gastrocolic ligament is tied with silk (Fig. 19.6).

For better mobility and freer anastomosis of the ends of the transverse colon after its resection, the hepatic-colic ligament is also cut between the clamps on the right, and the diaphragmatic-colon ligament on the left, and thus both bends of the colon are mobilized.

The mesentery of the transverse colon is crossed between the clamps in parts as far as possible from the intestinal wall and tied with silk. In case of cancer, one should strive to remove the lymph nodes along the vessels.

The middle colic artery is ligated separately with two silk ligatures near the place of origin from the superior mesenteric artery and crossed (Fig. 19, c). In cancer, it is advisable to ligate the artery and vein at the beginning of the operation, as well as tie the intestine with a gauze strip above and below the tumor in order to prevent hematogenous and implantation metastasis during manipulations on the intestine.

In benign processes in the transverse colon, it is advisable to keep the middle colon artery, and cut and tie only its branches that go directly to the removed part of the intestine.

In case of cancer of the middle third of the transverse colon in the absence of metastases in the regional lymph nodes (I-IIA stage), it is considered acceptable to resect the intestine with a tumor to the right and left bends, leaving them. At the same time, the middle colic artery is not tied up, but only its branches are tied up [Bronstein B. L., 1956]. The line of intersection of the intestine should be at least 5 cm from the edges of the tumor [Demin VN 19641. Before resection of the transverse colon, the abdominal cavity is fenced off with gauze swabs. Rigid intestinal clamps are applied to the removed part of the transverse colon on both sides of the tumor (from the side of the right and left bends), and soft clamps are applied to the remaining ends of the intestine, the intestine is cut between them with an electric knife or a scalpel and removed. The ends of the intestine are treated with a 3% alcohol solution of iodine.

The patency of the colon is restored by applying end-to-end anastomosis with two-row interrupted silk sutures according to the usual method (Fig. 20). When tensioning the anastomosed ends of the transverse colon in order to freely apply the anastomosis, it is recommended to mobilize both bends by cutting between the clamps on the right the hepatic colon ligament, and on the left the diaphragmatic colon ligament. If there is still tension in the anastomosed ends of the intestine, then it is advisable to additionally remove the left flexure and the descending colon, and then apply a transverse sigmoid anastomosis.

After performing the anastomosis, the resulting window in the mesentery is sutured with interrupted silk sutures so that loops of the small intestine do not get in or become pinched.

Rice. 20. End-to-end anastomosis. Stages of the operation.

a - application of seromuscular interrupted silk sutures to the posterior wall of the anastomosis (outer row of sutures); b-application of interrupted sutures through all layers of the posterior wall of the anastomosis (inner row of sutures); c-application of screw-in interrupted sutures on the anterior wall of the anastomosis (inner row of sutures); d-application of seromuscular interrupted silk sutures on the anterior wall of the anastomosis (outer row of sutures). Stitching the edges of the mesentery of the transverse colon.

The remaining part of the transverse colon is sutured with interrupted silk sutures to the edges of the gastrocolic ligament.

To unload the anastomosis, especially with insufficient bowel preparation, it is recommended to apply a cecostomy using the method described above. The laparotomy wound is sutured in layers.

The scope of radical surgery for colon tumors can be different: hemicolectomy, segmental resection.

For cancer of the cecum and ascending colon, a right-sided hemicolectomy is indicated with removal, in accordance with the characteristics of lymphogenous metastasis, 20-25 cm of the ileum, cecum, ascending and right half of the transverse colon (to the level of the middle intestinal artery) with excision in a single block of the posterior layer of the peritoneum with blood vessels and lymphatic vessels and nodes and all retrointestinal tissue.

For cancer of the hepatic flexure and the right third of the transverse colon, right-sided hemicolectomy is also indicated, since these tumors metastasize to the lymph nodes located along all three colonic arteries. The transverse colon is resected at the border of the middle and left thirds. For a small tumor of the middle third of the transverse colon without signs of regional metastasis, segmental resection is possible, moving 6-7 cm from the edge of the tumor in both directions; The middle colonic artery and the accompanying vein are crossed, and the mesentery containing lymphatic vessels and nodes is excised. If regional metastases are detected along the vessels of the right half of the colon, which is not uncommon, then in this case an extended right hemicolectomy with intersection of the transverse colon in the left third is indicated.

If the tumor is localized in the left third of the transverse colon, splenic flexure or descending colon, left hemicolectomy with resection of the colon in the left third is indicated; in one block, the colon mobilized to the mobile part of the upper third of the sigmoid is excised with the left colonic artery transected, the posterior layer of the peritoneum with vessels, lymph nodes and retroperitoneal tissue. A small tumor of the proximal sigmoid colon without metastasis can be resected segmentally (in other cases, left-sided hemicolectomy is indicated). For primary multiple cancer, the operations of choice are subtotal colectomy or total proctocolectomy.

Mobilization begins from the right lateral recess. The intestine is retracted medially, the parietal peritoneum is dissected from the top of the caecum to the hepatic flexure, retreating 1.5-2 cm from the edge of the intestine. In a blunt way, the intestine is exfoliated medially and downward throughout, along with the parietal peritoneum and retroperitoneal tissue. The preparation should be in an appropriate layer so as not to damage the descending and horizontal parts of the duodenum, the right ureter and the inferior vena cava (small vessels are tied up and crossed). The hepatic flexure is released by crossing the right phrenic-colic ligament between the clamps (may be mild and even absent) and ligating the vessels.

To mobilize the transverse colon, the gastrocolic ligament is crossed with preliminary ligation throughout the intended resection, as well as the greater omentum. The removed omentum and intestine are brought into the wound upward-laterally, opening access to the mesentery. The mesenteric vessels are ligated at the required level and crossed between the clamps. In case of cancer, the vessels should be divided as centrally as possible to remove a large number of lymph nodes. The abdominal cavity is fenced off from the removed intestine with napkins.

The ileum and transverse colon are dissected between two clamps and the specimen along with the tumor is removed: first, the ileum is crossed, the distal stump is wrapped with gauze, and the proximal stump is sutured in two layers with silk (if an end-to-side anastomosis is provided, the stump is not sutured, but covered with gauze napkin); then the transverse colon is crossed between the clamps and the distal (remaining) stump is sutured with silk interrupted sutures in two layers (suturing and cutting can be done using the UKL-60 apparatus, which makes it possible to perform a side-to-side anastomosis).

Transverse anastomosis is performed in such a way that the incision of the colon falls on the free muscle band. When forming an end-to-side ileotransverse anastomosis, the proximal end of the ileum is fixed to the transverse colon using stay sutures and the first row of interrupted gray-serous (serous-muscular) sutures (thin silk, atraumatic needle) is applied, taking into account the incision along the muscle band . The area of ​​the anastomosis is isolated with gauze and the lumen of the colon is opened, stepping back 0.5 cm from the suture line. The intestinal clamp is removed from the ileum, the mucous membrane and the lumen of the intestines are treated with a 2% alcohol solution of iodine, the posterior lips of the anastomosis are sutured with the transition to the anterior ones (a continuous or nodal suture with chrome-plated catgut or silk). The gauze wipes are removed, gloves are changed (hands are treated with antiseptics), the formation of the anastomosis is completed by applying a second row of gray-serous sutures along its anterior surface.

We consider side-to-side anastomosis to be more reliable, optimal, and with hardware processing. It should only be taken into account that it is unacceptable to leave large blind stumps in which feces accumulate and inflammation develops. It is convenient to perform anastomoses using the NICA apparatus. With the manual method, the sutured stumps are brought together and fixed on the anti-mesenteric side of the ileum with sutures-holders in the area of ​​the free tape, with the expectation that an anastomosis plane 5-6 cm long will pass along it. 7-0.8 cm from one another according to the method described above. The lumen of the ileum is opened, the edges are captured with Alice clamps, the contents of the intestine are dried with tupfers, the mucosa is treated with iodine. The lumen of the colon is opened and processed in the same way and the formation of the anastomosis is completed (catgut interrupted sutures through all layers around the circumference of the anastomosis and silk seromuscular sutures to the anterior wall).

The operation is completed by suturing the gap in the mesentery remaining after the anastomosis (prevention of strangulation of small intestinal loops), and the defect in the posterior layer of the peritoneum that arose after removal of the intestine (interrupted or continuous suture).

The abdominal cavity is sutured tightly in layers; microirrigators for administering antibiotics.

Resection of the transverse colon is usually performed for cancer localized in its middle sections, more precisely throughout the second and third quarters of the colon. In cases where the tumor is located in the marginal parts of the transverse colon, i.e., adjacent to its hepatic or splenic flexures, more extensive resections should be performed - right hemicolectomy or simultaneous removal of the descending colon. Resection can also be performed for gastrotransverse colon fistulas or other non-malignant lesions.

Patient preparation - as for all radical operations on the colon.

The position of the patient- on the back with a flat pillow under the lower back.

Pain relief - intratracheal anesthesia, ether-oxygen or azeotropic mixture.

The incision of the abdominal wall is transverse, 1-2 cm above the palpable tumor or 5 cm above the navel with a transverse intersection of the rectus abdominis muscles (Fig. 177. 1). After opening the abdominal cavity, the extent of the tumor and the presence or absence of metastases in the liver and lymph nodes are determined by palpation. Gastrocolic ligament (tig. gastrocoiicum) cut carefully closer to the stomach between two Bilvroth forceps. The surgeon's index finger is inserted into the cavity of the lesser omentum and then, under the control of this finger, the gastrocolic ligament is crossed between the clamps and ligated (Fig. 177.2) in such a way as to release in excess in both directions the entire area of ​​the transverse colon to be removed (do not damage the mesentery of the transverse colon).

The greater omentum is lifted and freed entirely from the transverse colon using scissors in the avascular zone (Fig. 177. 3). It is then cut between the clamps at the right and left corners of the wound and completely removed.

The transverse colon along with the tumor is pulled upward by the assistant. The surgeon places 2 clamps on the intestine on both sides of the area to be removed - one (closer to the tumor) hard narrow (Ochsner), second, on 2 cm from the first it is soft - better covered with rubber.

Then, using transillumination of the mesentery colonis transversi The transilluminator determines the course of the middle colonic artery and the nature of the marginal artery or ‘marginal arcades of the intestine. When cutting off the adjacent portion of the mesentery, it is recommended, if possible, to preserve the integrity art. collect media and ligate only the branches going to the center, as well as the marginal artery of the transverse colon (Fig. 177.4).

After removal of the affected section of the transverse colon, the soft terminals approach each other and the surgeon, having lubricated the mucous membranes of both stumps with iodine tincture, proceeds to apply an end-to-end anastomosis (see also fig. 171. 5. 6. 7. 8).

Initially, we impose knotty posterior serous-muscular sutures, retreating 1-1.5 cm from the cut edge of the intestine (rice.

177.5). Then the surgeon also uses an interrupted suture to place first the posterior and then the anterior row of anastomotic sutures through all layers of the intestine. (rice.177.6). After this, the soft terminals are removed, and a second anterior seromuscular row of sutures is applied with separate threads. Finally, the window in the mesentery is carefully sutured colonis transversi(Fig. 177.7). Residual rim hanging on the stomach Lig. gastrocolicum it is sutured with 4-5 thin sutures to the upper edge of the transverse colon. An antibiotic solution is poured into the abdominal cavity.

When closing the abdominal cavity, it is necessary to carefully sew together with strong silk both the anterior and posterior walls of the vagina of the rectus abdominis muscle (together with the muscle tissue). Cecostamia (see page 198, fig. 153) After this operation we consider it mandatory.

1. Cross section of the anterior abdominal wall at 5 cm, above the navel or 1-2 cm above the palpable tumor.

2. The gastrocolic ligament is cut at the finger using scissors between the clamps Bilvrota.

3. The greater omentum is separated from the transverse colon with scissors along the avascular zone.

Rice. 177. Resection of the transverse colon:

4. After dividing its mesentery, 2 pairs of clamps are applied to the transverse colon; the vessels supplying the colon are visible.

5. The posterior row of knotted sutures of the end-to-end anastomosis was applied.

6. Silk sutures are applied to the anterior and posterior wall of the anastomosis.

7. Completed anterior serous-muscular row of anastomotic sutures; sutures were placed on the window in the mesentery.

Resection of the transverse colon is performed in case of extensive damage to its wall, wounds of the middle colon artery, as well as in case of malignant tumors. An indication for this operation is also the growth of stomach cancer into the intestinal wall or its mesentery. Resection of the transverse colon in such cases is performed in combination with gastric resection for cancer.

Operation technique. The abdominal cavity is opened with an upper midline incision. The transverse colon is removed into the surgical wound. At the site of the intended resection, the gastrocolic ligament is cut off, and the mesentery of the transverse colon is ligated and transected. The ligation of the mesentery should be done carefully so as not to damage a. colicae mediae and its branches feeding the remaining sections of the intestine.

The removed part of the intestine is clamped on one side and the other with crushing intestinal splints, and silk stay sutures are placed on the remaining sections of the intestine along the free and mesenteric edges. The intestine is crossed along the edge of the crushing pulp and the drug is removed. The application of the pulp and the intersection of the intestine should be done somewhat obliquely, removing large sections of the intestine along its free edge so that the diameters of the lumen of both ends are the same. To avoid tension of the remaining sections of the intestine during the anastomosis, circular resection should not be performed for more than 20 cm (A. V. Melnikov). Both ends of the intestine are brought to each other using stay sutures.

Then the anastomosis begins. A continuous marginal catgut suture is applied to the posterior lips of the anastomosis. The same thread is used to apply a furrier's suture to the anterior lips of the anastomosis. Having finished the imposition of a continuous seam, the initial and final threads are tied and their ends are cut off. Change napkins, tools and wash hands. After this, seromuscular interrupted sutures are applied first to the posterior and then to the anterior wall of the anastomosis. The hole in the mesentery of the transverse colon and the gastrocolic ligament is sutured with separate interrupted sutures. The abdominal wall wound is sutured tightly.

“Atlas of operations on the abdominal wall and abdominal organs” V.N. Voylenko, A.I. Medelyan, V.M. Omelchenko

In the left groin area, a quadrangular flap of skin measuring 10x15 cm is cut out with the base directed towards the upper two-thirds of the inguinal ligament. The flap is separated and turned downwards. At the base of the flap, parallel to and above the inguinal ligament, the aponeurosis of the external oblique abdominal muscle is dissected. The internal oblique and transverse abdominal muscles are bluntly dissected and the parietal peritoneum is opened. A loop is brought into the wound ...

The edges of the intestine are grasped with clamps and the mucous membrane is wiped with 3% iodine tincture. Then the edges of the intestinal incision are sutured with 5-6 sutures to the skin incision of the perineum. A cotton-gauze bandage is applied to the perineal area. The catheter is removed on the 3rd-4th day, and gauze pads - on the 7th day after the operation. Scheme of the operation in the finished form "Atlas of operations on the abdominal wall and abdominal organs ...

The formation of a skin sheath around the removed portion of the sigmoid colon. Suturing a skin wound To hold gases and feces, the formed proboscis-shaped artificial anus is tied up with a gauze ribbon. "Atlas of operations on the abdominal wall and abdominal organs" V.N. Voylenko, A.I. Medelyan, V.M. Omelchenko

Ileotransversostomy. Transversosigmostomy Ileotransversostomy is performed for inoperable malignant neoplasms, multiple stenoses and ulcers of the right colon. The anastomosis is placed between the terminal ileum and the transverse colon. For incomplete shutdown of the right half of the colon, an anastomosis is applied in a side-to-side manner. If it is necessary to completely turn off the affected section of the intestine, then an anastomosis is applied according to the end type ...

Bowel resection.

Radical excision of the colon tumor along with the corresponding part of the mesentery with vessels and accompanying lymphatic vessels and nodes is the most suitable for local elimination of the tumor. Occasionally, extremely limited resection may be appropriate in unsuitable patients or in widespread tumors.

With classical resection, the lymphatic vessels lying along the arteries feeding the intestinal area are removed, which is accompanied by ischemia of the colon, therefore, with a right-sided hemicolectomy, the ileocolic and right colic arteries are removed, when removing the transverse colon, the middle colic artery is removed, and with a left-sided hemicolectomy, the left one is removed colon artery. However, resection of the transverse colon is not recommended due to the fact that anastomotic failure is unacceptably high, and the choice between left hemicolectomy and resection of the sigmoid colon is inappropriate, given the principle of radical removal of the tumor along with the feeding vascular pedicle. Thus, many are now of the opinion that the decision on the type of operation lies between right and left colectomy, with increasing extent of resection depending on the location of the tumor.

A standard right hemicolectomy involves dividing the ileocolic and right colic arteries at their origin in the superior mesenteric artery. The marginal artery or right branch of the middle colic artery also needs to be divided for complete vascular isolation. For tumors of the descending colon and sigmoid colon, the conventional left hemicolectomy involves dividing
the inferior mesenteric artery at its origin from the aorta.

Carcinoma of the splenic (left) flexure of the colon

The main controversy arises with tumors in the area of ​​the left splenic (left) flexure, with two options possible. In the first case, the tumor is considered as left-sided, a left-sided hemicolectomy is performed, the inferior mesenteric artery is divided at its origin, and the left branch of the middle colic artery is also divided. A more conservative approach to this operation is to preserve the trunk of the inferior mesenteric artery, but this is essentially a segmental resection. Another approach is to perform an extended right hemicolectomy, dividing the middle colic artery and the descending branch of the left colic artery.

Experts are divided on which approach to take, but a left hemicolectomy will inevitably require an anastomosis between the right colon and rectum, which may be difficult to perform without tension in some patients.

In addition, the blood supply to the colon is variable. In 6% of cases, the left colic artery is absent; the blood supply to the splenic flexure comes from the middle colic artery. In 22% of cases, the middle colic artery is absent, and the blood supply to the splenic flexure is from the left and right colic arteries. Surgery for cancer involves removal of the tumor along with the lymphatic vessels draining it, and since the lymphatic vessels accompany the feeding arteries, it makes sense to ligate the right, middle and left colic arteries, which will make a right hemicolectomy necessary.

For these reasons, I prefer an extended right hemicolectomy with an anastomosis between the sigmoid colon and a mobilized, well-vascularized ileum. However, it should be emphasized that the ideal operation is dictated by individual anatomy, the most important criterion being the absence of tension and good blood supply, as evidenced by brisk bleeding and good color of the cut ends of the intestine.

The "" program revealed a high rate of local recurrence and poor survival
patients with splenic angle carcinoma, regardless of stage and clinical manifestations, which may reflect the inadequacy of primary surgical treatment.

Tumors in advanced stages

In the presence of local tumor invasion, it is still possible to achieve radical resection if the surgeon prepares the adjacent involved organs for resection, such as the ureter, duodenum, stomach, spleen, small intestine, bladder and uterus. In addition, about 5% of women will have macroscopic ovarian metastases, another 2% will have microscopic ones. For this reason, some surgeons perform routine oophorectomy on all women with colorectal cancer.

In patients with truly unresectable colon tumors, ileocolic anastomosis may be appropriate for right-sided tumors, whereas colostomy may be preferable for distal colon tumors. For multiple colon tumors, subtotal or total colectomy should be considered.

Surgical technique for colon cancer

Right hemicolectomy

A midline incision is preferred for all colon resections because it avoids muscle damage and allows access to all parts of the abdomen and pelvis. For right hemicolectomy, it is better to have two-thirds of the incision above the umbilicus to better mobilize the hepatic flexure.

With the surgeon standing to the patient's left, the right side of the colon is pulled toward the midline and the peritoneum is incised in the right lateral canal. The incision continues from the dome of the cecum to the hepatic flexure, distal to this point the cavity of the lesser omentum is entered, and the greater omentum is dissected below the gastroepiploic arcade to the point where the transverse colon is crossed. The right side of the colon is then retracted to the midline, and the tissue in the plane between the mesentery of the transverse colon and the posterior wall of the abdominal cavity is carefully dissected using a diathermocoagulator or scissors, being careful not to damage the duodenum. If this is done, the ureter and genital vessels should be retracted to the side without damaging them.

Then it remains to cross the corresponding vessels of the colon, as described above; their isolation can be facilitated by transillumination of the mesentery. Once this is accomplished, the intestinal wall is isolated and one crush forceps is applied at the intersections of the intestine. Soft intestinal clamps can be applied proximally to the crushing forceps on the small intestine and distally to the colon, the intestine is crossed over the crushing clamps, leaving them on the resected intestine.

Left hemicolectomy

For all left-sided colon resections, it is recommended that the patient be positioned in the Lloyd-Davis position, as positioning the assistant between the patient's legs is advantageous and also allows the operating surgeon excellent access to the splenic flexure. (At St. Mark's Hospital, even for operations on the right side of the colon, patients are placed in the Trendelenburg lithotomy position, not only to position the surgeon, assistants, and operating room nurse around the operating table, but also because right-sided tumors or Crohn's disease may show involvement rectum.) A long midline incision is used, starting above the umbilicus and continuing to the symphysis pubis. The operating surgeon stands on the left side of the patient and one assistant retracts the sigmoid colon medially while the other retracts the left side of the anterior abdominal wall downwards.

The peritoneum lateral to the sigmoid and descending colon is dissected near the “white line” of the confluence using a diathermocoagulator or a scalpel. It then becomes possible to see the area between the mesentery and the structures of the retroperitoneum; for better visualization, traction of the intestine in the medial direction, carried out by the assistant, and pressure on the retroperitoneum with a forceps or clamp, carried out by the operating surgeon, should be combined.

This technique will ensure that the ureter and vessels of the internal genital organs are retracted to the side. The hypogastric nerve must be carefully identified and separated from the mesentery, otherwise it may be damaged during preparation of the rectum for anastomosis. The splenic flexure should then be mobilized and this is best accomplished by cutting the greater omentum from the transverse colon and continuing laterally towards the flexure. However, if the tumor is located in the area of ​​the splenic flexure, it is recommended to dissect the gastrocolic ligament and take a biopsy of the omentum. With any method there is a risk of rupture of the spleen when traction is applied to its peritoneal adhesions, and, despite extreme caution, it may sometimes be necessary. For small tears, however, the application of a hemostatic agent, such as oxycellulose, is effective.

Once the left colon is mobilized, the origin of the inferior mesenteric artery is identified by incising the peritoneum over the aorta near the descending duodenum, ligated, and divided. To achieve full mobility, the inferior mesenteric artery must be divided just below the inferior border of the pancreas. The colon is then transected as described for right hemicolectomy at appropriate locations in the transverse colon and rectosigmoid junction.

Non-contact technology for cancer

It is argued that early ligation of vessels before tumor mobilization (sometimes even supported by the use of proximal and distal occlusive bands around the bowel) prevents embolization by tumor cells and improves survival.

The technique was popularized by Rupert Tumbull of Cleveland, but a recent randomized controlled clinical trial in the Netherlands found no survival benefit.

Anastomosis

For anastomoses after colon cancer resection, hand suture is preferred, although it is recognized that machine suture can provide superior results.

Anastomosis with comparison of serous and submucosal layers

This method, originally described by Mathewson et al. (Matheson et al.), involves the use of a single-row interrupted suture with 3/0 braided polyamide thread. For mobile anastomoses (usually ileocolic), the first step is to ensure equal diameter of the ends of the anastomosed intestinal loops. This is achieved by making an incision along the antimesenteric edge of the small bowel, although some surgeons prefer to use an end-to-side anastomosis technique. One side of the anastomosis is created on the serous side of the bowel between the mesenteric and antimesenteric edges, placing sutures at 4 mm intervals and 4 mm in depth, ensuring that the muscular and submucosal layers, but not the mucosa, are sutured. All sutures are left untied until all sutures have been placed, then each knot is hand-tightened, ensuring sufficient tension but avoiding over-tightening. The half-completed anastomosis is then returned to the abdominal cavity and the process is repeated. The mesenteric defect is not sutured. For colorectal or ileocolic anastomosis, the posterior row of sutures is placed first, holding each with a special suture clamp or placing a separate vascular clamp on each suture. If arterial clamps are used, they should be threaded onto the clamp holder to avoid tangling. Again, the sutures are hand-tightened after all sutures have been sutured, the knots should be tightened on the luminal side of the anastomosis after the proximal end of the bowel has been pulled down along the sutures to the upper part of the rectum. The tendrils of the nodes are then cut off so that they are covered by the cut edge of the unstitched mucosa. Upon completion of the formation of the anastomosis on the posterior side, its anterior part is performed in a similar way, but tightening the nodes on the extraluminal side. The formation of this type of anastomosis is greatly facilitated by using a curved Heaney needle holder, placing the needle with the concave side away from the convex side of the needle holder jaws.

Anastomosis formed using a stapler

After right hemicolectomy, the most widely used hardware anastomosis is “functional end-to-end anastomosis.” In this case, the ends of the colon and ileum are sutured with a stapler (stapling device) at the time of tumor removal, and two small enterotomy holes are made to allow a linear cutting-suturing device to be inserted into the ends of the intestines. The anastomosis is then performed by closing the working surfaces of the stapler, being careful not to enter the mesentery into the jaws, and after checking the suture line for bleeding, the remaining defect is sutured using a linear stapler. After a left hemicolectomy, a true end-to-end anastomosis can be created using a circular stapler to form the anastomosis through the anus, although in some men the intact rectum may be difficult to pass.

Results of various methods of anastomosis formation

Junctional seromuscular anastomosis is recommended because of its convenience for any anastomosis involving the colon, in addition, when applying such anastomosis, according to large studies, the best results are observed (failure rate 0.5-3%).

Hardware suture has been compared with manual suture in several randomized trials. Although results varied, it appears that there is no difference (in failure rate) between these methods.

One study found strong evidence that tumor recurrence was less common in the suture group, but did not differentiate between rectal and colon resections.

Abdomen

Once the anastomosis is complete, many surgeons leave it in the abdominal cavity both to minimize the effects of anastomotic leakage and to prevent the accumulation of fluid that can become infected.

There is no evidence to support this practice, and three randomized trials have shown no benefit accompanying drainage for colonic or colorectal anastomosis.

The article was prepared and edited by: surgeon