The volume of radical surgery for tumors of the colon. 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 borders, scheme).

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

a - the boundaries of resection and the imposition of end-to-end ascendodescendoanastomosis with 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 colic 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 the 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 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), resection of the intestine with a tumor to the right and left bends is considered acceptable, 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 pass 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 dissecting between the clamps on the right side of the hepatocolic ligament, and on the left side of the phrenic-colic ligament. If, nevertheless, there is a tension of the anastomosed ends of the intestine, then it is advisable to additionally remove the left flexure and the descending colon, and then apply a transversosigmoid anastomosis.

After applying the anastomosis, the resulting window in the mesentery is sutured with interrupted silk sutures so that the loops of the small intestine do not get there and are not infringed.

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

a - the imposition of serous-muscular interrupted silk sutures on the posterior wall of the anastomosis (the outer row of sutures); b-imposition of interrupted sutures through all layers of the posterior wall of the anastomosis (inner row of sutures); c-imposition of screwing interrupted sutures on the anterior wall of the anastomosis (inner row of sutures); d-imposition of serous-muscular 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 rest 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 according to the method described above. The laparotomic wound is sutured in layers.

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

In cancer of the caecum and ascending colon, right-sided hemicolectomy is indicated with removal, in accordance with the characteristics of lymphogenous metastasis, of 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 of the posterior peritoneum with blood vessels in a single block. and lymphatic vessels and nodes and the entire post-intestinal fiber.

In 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. With a small tumor of the middle third of the transverse colon without signs of regional metastasis, segmental resection is possible, stepping back from the edge of the tumor in both directions by 6-7 cm; the middle colonic artery and the vein accompanying it are crossed, the mesentery containing the 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-sided hemicolectomy is indicated with the transection of the transverse colon in the left third.

If the tumor is localized in the left third of the transverse colon, splenic flexure or descending colon, left-sided hemicolectomy with resection of the colon in the left third is indicated; In one block, the large intestine mobilized to the movable part of the upper third of the sigma is excised with the transected left colonic artery, the posterior 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). In primary multiple cancer, the operations of choice are subtotal colectomy or total proctocolectomy.

Mobilization starts from the right lateral pocket. The intestine is retracted medially, the parietal peritoneum is dissected from the apex 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 dissection 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 ligated 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 during the proposed resection, as well as the greater omentum. The removed omentum and intestine are brought into the wound upward-laterally, opening access to the mesentery. Vessels of the mesentery are ligated at the required level and crossed between the clamps. In cancer, the vessels should be crossed 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 preparation together with the tumor is removed: first, the ileum is crossed, the distal stump is wrapped with a gauze cloth, and the proximal stump is sutured in two floors with silk (if 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 floors (suturing and cutting off can be done using the UKL-60 device, which makes it possible to apply side-to-side anastomosis).

Nleotransverse anastomosis is applied 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 with sutures-holders and the first row of nodal gray-serous (serous-muscular) sutures (thin silk, atraumatic needle) is applied, taking into account the incision along the muscle tape . 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 (the 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. The imposition of anastomoses is conveniently performed using the NJCA 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. Similarly, the lumen of the colon is opened and processed and the formation of the anastomosis is completed (catgut interrupted sutures through all layers along the circumference of the anastomosis and silk seromuscular sutures to the anterior wall).

The operation is completed by suturing the gap in the mesentery, which remains after the anastomosis (prevention of infringement of the loops of the small intestine), and the defect in the posterior peritoneum that has arisen after the removal of the intestine (nodal or continuous suture).

The abdominal cavity is sutured tightly in layers; microirrigators for the introduction of antibiotics.

Resection of the transverse colon is usually performed for cancer localized in its middle sections, more precisely, throughout the second and third quarter of the intestine. In cases where the tumor is located in the marginal sections of the transverse colon, i.e., next to its hepatic or splenic flexures, more extensive resections should be done - right-sided hemicolectomy or simultaneous removal of the descending colon. Resection may also be performed for gastrointestinal fistulas or other non-cancerous 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). Upon opening the abdominal cavity, palpation reveals the extent of the tumor and the presence or absence of metastases in the liver and lymph nodes. Gastrocolic ligament (tig. gastrocoiicum) dissected carefully closer to the stomach between two Bilvrot clamps. The index finger of the surgeon is inserted into the cavity of the lesser omentum and then, under the control of this finger, it is crossed between the clamps and the gastrocolic ligament is tied. (Fig. 177. 2) in such a way as to release with excess in both directions the entire section of the transverse colon to be removed (do not damage the mesentery of the transverse colon).

The greater omentum is lifted and completely released from the transverse colon with scissors along the avascular zone (Fig. 177. 3). Then it is dissected between the clamps in the right and left corner of the wound and completely removed.

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

Then, with the help of translucence 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 area of the mesentery, it is recommended, if possible, to keep intact art. collect media and bandage only its 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 the imposition of an anastomosis end to end (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 puts a knotted suture through all layers of the intestine, first the posterior and then the anterior row of anastomosis sutures (rice.177.6). After that, the soft terminals are removed, and the second anterior serous-muscular row of sutures is applied with separate threads. At the end, the window in the mesentery is carefully sutured colonis transversi(Fig. 177.7). Hanging on the stomach residual border Lig. gastrocolicum 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 both anterior and posterior walls of the vagina of the rectus abdominis muscle (together with muscle tissue) with strong silk. Cecostamia (see page 198, fig. 153) after this operation we consider 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 dissected on the finger with scissors between the clamps Bilvrot.

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 separation of its mesentery, 2 pairs of clamps are applied to the transverse colon, the vessels feeding the intestine 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 with extensive damage to its wall, wounds of the middle colon artery, as well as with malignant tumors. The indication for this operation is also the germination of gastric cancer in the intestinal wall or its mesentery. Resection of the transverse colon in such cases is performed in combination with resection of the stomach for cancer.

Operation technique. The abdominal cavity is opened with an upper median incision. The transverse colon is brought into the surgical wound. At the site of the proposed resection, the gastrocolic ligament is cut off, and the mesentery of the transverse colon is also ligated and crossed. Ligation of the mesentery should be done carefully so as not to damage a. colicae mediae and its branches that feed the remaining sections of the intestine.

The part of the intestine to be removed is squeezed from one side and the other with crushing intestinal sphincter, and silk sutures are applied to the remaining sections of the intestine along the free and mesenteric edge. Along the edge of the crushing pulps, the intestine is crossed and the drug is removed. The application of clamps 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. In order to avoid tension of the remaining sections of the intestine when anastomosis is applied, circular resection should not be performed for more than 20 cm (A. V. Melnikov). Both ends of the intestine are brought to each other by holding sutures.

Then proceed to the imposition of the anastomosis. A continuous marginal catgut suture is applied to the posterior lips of the anastomosis. With the same thread, a furrier suture is applied 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 that, serous-muscular interrupted sutures are applied first to the back, and then to the anterior wall of the anastomosis. A hole in the mesentery of the transverse colon and the gastrocolic ligament is sutured with separate interrupted sutures. The wound of the abdominal wall is sutured tightly.

"Atlas of operations on the abdominal wall and abdominal organs" V.N. Voilenko, A.I. Medelyan, V.M. Omelchenko

In the left inguinal region, a quadrangular skin flap 10×15 cm in size is cut out with the base directed to the upper two thirds of the inguinal ligament. The flap is separated and turned down. At the base of the flap, parallel to and above the inguinal ligament, the aponeurosis of the external oblique muscle of the abdomen is dissected. The internal oblique and transverse abdominal muscles are bluntly stratified 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 perineal skin incision. A cotton-gauze bandage is applied to the perineal region. 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. Voilenko, 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 ...

Intestinal resection.

Radical excision of the tumor of the colon, together 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.

During classical resection, the lymphatic vessels lying along the arteries that feed the intestine are removed, which is accompanied by ischemia of the large intestine, therefore, with a right-sided hemicolectomy, the iliac and right colon arteries are removed, with the removal of the transverse colon, the middle colon artery is removed, and with a left-sided hemicolectomy, the left colonic artery. However, resection of the transverse colon is not recommended due to the fact that the insufficiency of the anastomosis with it is unacceptably high, and the choice between left-sided 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 is between right-sided and left-sided colectomy with an increase in the amount of resection depending on the location of the tumor.

A standard right hemicolectomy involves transection of the iliococolic and right colic arteries at their origin in the superior mesenteric artery. The marginal artery, or right branch of the middle colic artery, must also be divided for complete vascular isolation. For tumors of the descending colon and sigmoid colon, the conventional left-sided hemicolectomy involves transection
inferior mesenteric artery where it originates from the aorta.

Carcinoma of the splenic (left) flexure of the colon

The main disputes arise with tumors in the region of the left splenic (left) flexure, and two options are possible. In the first case, the tumor is considered as left-sided, a left-sided hemicolectomy is performed, the inferior mesenteric artery is crossed at the site of its discharge, and the left branch of the middle colon artery is also crossed. 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-sided hemicolectomy, which cuts the middle colic artery and the descending branch of the left colic artery.

Expert opinion is divided on which approach to choose, but a left-sided hemicolectomy will inevitably entail an anastomosis between the right colon and the rectum, which can be difficult to perform without tension in some patients.

In addition, the blood supply to the colon is not constant. In 6% of cases, the left colic artery is absent, the blood supply to the splenic flexure is 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 the removal of the tumor along with the lymphatics that drain it, and since the lymphatics accompany the supplying arteries, it makes sense to ligate the right, middle, and left colic arteries, which would necessitate a right-sided hemicolectomy.

For these reasons, I prefer an extended right hemicolectomy with 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.
The majority of patients with carcinoma of the splenic angle, regardless of the stage and clinical manifestations, which may reflect the inadequacy of the primary surgical treatment.

Tumors in advanced stages

In the presence of local tumor invasion, it is still possible to achieve a radical resection if the surgeon prepares for resection the adjacent organs involved, 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 a truly inoperable colon tumor, an ileocolic anastomosis may be appropriate for a right-sided tumor, while a colostomy may be preferable for tumors of the distal colon. For multiple tumors of the colon, subtotal or total colectomy should be considered.

Operative technique for colon cancer

Right hemicolectomy

The median incision is preferred in all colonic resections because it does not damage the muscles and allows access to all parts of the abdomen and pelvis. For right-sided hemicolectomy, it is best to have two-thirds of the incision above the umbilicus for better mobilization of the hepatic flexure.

If the surgeon is standing to the left of the patient, the right part of the colon is pulled towards the midline and the peritoneum is dissected in the right lateral canal. The incision continues from the dome of the caecum to the hepatic flexure, distal to this point enters the cavity of the lesser omentum, and the greater omentum is dissected below the gastroepiploic arcade to the point where the intersection of the transverse colon is planned. The right part 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 abdominal wall is carefully dissected with a diathermocoagulator or scissors, care must be taken not to damage the duodenum. If this is done, the ureter and genital vessels should be moved aside without damaging them.

Then it remains to cross the corresponding vessels of the colon, as described above, their isolation can be facilitated by translucence of the mesentery. Once this is done, the intestinal wall is exposed and one crushing clamp is applied at the intersections of the intestine. Soft intestinal clamps can be applied proximal to the crusher on the small intestine and distally on the colon, the intestine is crossed along the crushing clamps, leaving them on the resected colon.

Left hemicolectomy

For all left-sided colon resections, it is recommended to place the patient in the Lloyd-Davies position, as the position of the assistant between the patient's legs is advantageous and also allows the operating surgeon to have excellent access to the splenic flexure. (At St. Mark's, 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 in right-sided tumors or Crohn's disease, involvement can be found rectum.) A long midline incision is made, starting above the umbilicus and continuing to the pubic articulation. The operating surgeon stands on the left side of the patient and one assistant retracts the sigmoid colon medially while the other pulls down the left side of the anterior abdominal wall.

The peritoneum lateral to the sigmoid and descending colon is dissected near the "white line" of the confluence using a diathermocoagulator or a scalpel. Then it becomes possible to see the area between the mesentery and the structures of the retroperitoneal space, for better visualization, it is necessary to combine the traction of the intestine in the medial direction, carried out by an assistant, and pressure on the retroperitoneal space with a forceps or clamp, carried out by the operating surgeon.

This technique will ensure that the ureter and the vessels of the internal genital organs are laid aside. 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 done by cutting off the greater omentum from the transverse colon and proceeding laterally towards the flexure. However, if the tumor is located in the area of the splenic flexure, it is recommended to dissect the gastrointestinal ligament and take a biopsy of the omentum. With any method, there is a risk of rupture of the spleen during traction for its peritoneal adhesions, and, despite extreme caution, it may sometimes be necessary. For small tears, however, the application of a hemostatic agent such as hydroxycellulose is effective.

Once the left colon is mobilized, the origin of the inferior mesenteric artery is identified by dissecting the peritoneum over the aorta near the descending duodenum, ligated, and transected. To achieve full mobility, it is necessary to cross the inferior mesenteric artery just below the inferior border of the pancreas. The colon is then transected as described for a right-sided hemicolectomy at suitable locations in the transverse colon and rectosigmoid junction.

Non-contact technology for cancer

It has been argued that early vascular ligation prior to tumor mobilization (sometimes even reinforced by the use of proximal and distal occlusive bandages 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 showed no survival benefit.

Anastomosis

For anastomoses after resection of colon cancer, manual suture is better, despite the recognition that machine suture can provide excellent results.

Anastomosis with comparison of the serous and submucosal layers

This method, originally described by Mathewson et al. (Matheson et al.), involves the use of a single-row knotted suture with a braided 3/0 polyamide thread. For mobile anastomoses (usually ileocolic), the first step is to ensure that the ends of the anastomosed intestinal loops are of equal diameter. This is achieved by making an incision along the antimesenteric rim of the small intestine, although some surgeons prefer to use the end-to-side anastomosis technique. One side of the anastomosis is formed from the serous side of the bowel between the mesenteric and antimesenteric margins, placing sutures at 4 mm intervals and 4 mm deep, ensuring that the muscular and submucosal layers, but not the mucosa, are sutured. Until all sutures have been applied, they are left untied, then each knot is tightened by hand, providing sufficient tension, but avoiding overtightening. The half-finished anastomosis is then returned to the abdominal cavity and the process repeated. The mesenteric defect is not sutured. In colorectal or ileocolic anastomosis, the posterior row of sutures is applied 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. Once again, the sutures are manually 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 intestine has been pulled down along the sutures to the upper rectum. The tendrils of the nodes are then cut off so that they are covered by the cut edge of the unsewn mucosa. Upon completion of the formation of the anastomosis along the posterior side, its anterior part is performed in a similar way, but tightening the knots on the extraluminal side. The formation of this type of anastomosis is greatly facilitated when using a curved Heaney needle holder, placing the needle with the concave side of the convex side of the needle holder jaws.

Anastomosis formed with a stapler

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

Results of various methods of anastomosis formation

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

Mechanical suture has been compared with manual suture in several randomized trials. Although the results varied, there appears to be no difference (in failure rate) between the methods.

One study provided strong evidence that tumor recurrence was less common in the suture group, but no distinction was made between rectal and colonic resections.

abdominal cavity

Once the anastomosis has been formed, many surgeons leave it in the abdomen, both to minimize the effects of anastomotic leakage and to prevent fluid accumulation that can become infected.

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

The article was prepared and edited by: surgeon