A novel technique for enterotomy closure in stapled laparoscopic intracorporeal anastomosis. (3rd October 2017)

• Record Type: Journal Article
• Authors: di Saverio, S.; Birindelli, A.; Segalini, E.; Todero, S.; Botusan, R. A.; Novello, M.; Kwan, S.; Biondi, A.
• Is Part Of: Colorectal disease. Volume 19:Number 10(2017)
• Page Start: O372
• Page End: O376
• Publication Date: 2017-10-03
• Subjects: Laparoscopic colorectal surgery -- intracorporeal anastomosis -- laparoscopic suturing -- right colectomy -- ileo‐colic anastomosis -- surgical technique education; Colon (Anatomy) -- Diseases -- Periodicals; Rectum -- Diseases -- Periodicals; 616.34
• DOI: 10.1111/codi.13856
• Languages: English
• ISSNs: 1462-8910

Abstract

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.