Anastomosis of the intestine is a process of surgery that is used for development of communication between two formerly distant portions of the intestine. This procedure restores intestinal continuity after removal of a pathologic condition affecting the bowel. Anastomosis of the intestine is surgery which is most commonly performed, especially in the emergency case and is also commonly performed in the elective setting when resections are carried out for benign or malignant lesions of the gastrointestinal tract.
The difficulty of anastomosis in intestine is leak in anastomosis which results in peritonitis in association with high morbidity and mortality. Most common technique and adherence to fundamental principles, Proper surgical technique and adherence to fundamental principles are imperative to ensure successful outcome after intestinal anastomosis.
What are the indications of intestinal anastomosis?
Indications are of two types:
-  Restoration of bowel continuity after resection of diseased bowel
Resection of diseased bowel is performed in the following settings:
-  Bypass of unresectable diseased bowel.
- Bowel gangere secondary to vascular compromise from mesenteric vascular disease, prolonged intestinal obstruction, intussusceptions, or volvulus
- Difficult condition such as intestinal polyps, intussusception, or roundworm infestation with intestinal obstruction
- Infections, such as tuberculosis complicated with stricture or perforation
- Traumatic perforations
- Large perforation (traumatic) not amenable to primary closure
- Bypass of unresectable diseased bowel
Bypass of unresectable diseased bowel is performed in the following settings:
- Locally advanced tumor causing luminal obstruction
- Metastatic disease-causing intestinal obstruction
- Poor general condition or condition that prevents major resection
- Pediatric conditions
Pediatric conditions for which intestinal anastomosis may be required include the following:
- Congenital anomalies, such as Meckel diverticulum, intestinal atresia, malrotation with volvulus leading to gangrene, meconium ileus, duplication cysts, and Hirschsprung disease
- Inflammatory conditions, such as necrotizing enteritis, enterocolitis, tuberculosis, and enteric perforation
What are the contraindications of intestinal anastomosis?
Anastomosis of the intestine
is contraindicated in conditions in which light is a high risk of anastomosis leak, such as the following:
- Severe sepsis
- Poor nutritional status (e.g, severe hypoalbuminemia)
- Disseminated malignancy (multiple peritoneal and serosal deposits, ascites)
- Viability of bowel in doubt
- Fecal contamination or frank peritonitis
- Unhealthy bowel condition (precludes primary anastomosis)
What are the complications of Intestinal Anastomosis?
Important complications following intestinal anastomosis include the following:
- Anastomotic Leak
- Wound infection
- Anastomotic stricture
- Prolonged functional ileus, especially in children
What is the bowel resection in Intestinal Anastomosis?
The portion of the bowel to be resected should be adequately mobilized. A rare problem of mobilization is with the small bowel, which can be easily brought to the surface. Therefore big bowel especially the retroperitoneal
segments should be adequately mobilized by dividing the lateral peritoneal reflection. Bowel mobilization, in addition to facilitating resection, ensures tension-free anastomosis.
When mobilization of the bowel is finished, then next step covered will be after mobilization of the bowel, the next step will be division of the mesentery
. Principles to be followed in division of the mesentery include the following:
- Tran illumination to identify mesenteric blood vessels
- Isolation of vessels by dividing surrounding fat
- Division between clamps
- Ligation with suitable incision, the mesenteric vessels supplying the part to be excised are identified and divided after ligation to prevent knot slippage
What are the controversies of intestinal anastomosis?
Single-layer vs double-layer anastomosis:
is traditionally performed in two layers. Low-coming of two types of technique is boring and big time waster for the performance. The shortcoming of the two-layer technique is that it is somewhat tedious and time-consuming to perform.
Advantages of a single-layer technique are that they are less time consuming and their cost is low in which safety is the main issue. However, randomized trials and meta-analyses comparing the two techniques of intestinal anastomosis did not find increases in the rate of anastomosis leak, the incidence of preoperative complications
How is the technique used in children?
The bowel loop with the pathologic
finding is isolated. Stable position of gentle bowel is necessary throughout the procedure. Intestine of non-crushing clamps is used for the isolation of loop. The vessels which are mesenteric supplies a part to be excised that are identified and divided after ligation with silk ligatures.
The intestinal loop is excised, and the cut edges are examined for bleeding and viability. If viability is doubtful, more bowels are excised. Amount of adequacy of the lumen is ensured and the anastomosis is performed with interrupted sutures in a single layer. The most commonly used suture material is polyglactin 910. Most often Intraluminars
staplers are used for intestinal anastomosis and are said to reduce the operating time of most surgeons.
What are the controversies of intestinal anastomosis?
Single-layer vs double-layer anastomosis
Intestinal anastomosis is traditionally performed in two layers. Low-coming of two types of technique is boring and big time waster for the performance. The shortcoming of the two-layer technique is that it is somewhat tedious and time-consuming to perform. Advantages of the single-layer technique is that they are less time consuming and their cost is low in which safety is the main issue. However, randomized trials and meta-analyses comparing the two techniques of intestinal anastomosis did not find increases in the rate of anastomosis leak, the incidence of preoperative complications, mortality.
The minimum cost of single intestinal resection and anastomosis is Rs. 3,50,000 to maximum Rs. 7,00,000.