Operative Surgery and Topographic Anatomy - 2016

Content Module No. 3. Topographic Anatomy and Operative Surgery of the Abdominal Regions and Organs

Topic 16. Intestinal Sutures. Closure of Small Intestine Wounds. Small Bowel Resection. Types of Intestinal Anastomoses: End-to-End, Side-to-Side, Enteroanastomoses, End-to-Side

1. Relevance of the topic: abdominal trauma involving small bowel injury, atresia, and intestinal necrosis as a complication of mechanical intestinal obstruction require emergency surgery. Therefore, mastering the technique of intestinal suturing, The ability to close an intestinal wound, perform bowel resection, and construct an enteroanastomosis are essential surgical skills frequently applied in clinical practice.

2. Specific objectives:

1. To analyze the technique of intestinal suturing.

2. To explain how to construct enteroanastomoses.

3. To explain how to perform small bowel wound closure and intestinal resection.

3. Assignments FOR INDEPENDENT study in preparation for the Class.

3.1. List of key terms, parameters, and characteristics to be mastered by the student in preparation for the class:

3.2. Theoretical questions for the class:

1. What types of intestinal sutures do you know?

2. Advantages and disadvantages of various types of intestinal sutures.

3. What are the indications for small bowel resection? Stages of the operation depending on the size of the resected area.

4. Types of enteroenteric anastomoses, their construction technique, and the anatomo-physiological rationale for choosing the surgical method. Potential complications.

3.3. Practical skills acquired during the class:

1. Placement of intestinal sutures.

2. Construction of end-to-end and side-to-side anastomoses.

4. Subject matter content

The student group is divided into surgical teams. Each team performs a bowel resection and a side-to-side or end-to-end anastomosis on a cadaver or isolated segments of the Small Intestine with its mesentery. Throughout this Procedure, strict asepsis must be maintained; therefore, the surgery is performed on an organ exteriorized from the Abdominal cavity AND carefully isolated from it using surgical Sponges. Gentle handling of Tissues and The Use of appropriate instrumentation (intestinal clamps, anatomical forceps, round-bodied needles, etc.) are crucial. Vessels during bowel mobilization are ligated close to the intestinal wall. In cases of malignant tumors, ligation is performed further away, yet distal to the first-order arcade, to prevent Necrosis of the remaining bowel segment (Fig. 54).

Fig. 54. Mobilization of a segment of the small intestine.

a - parallel detachment of the mesentery; b - wedge-shaped detachment.

There is an important fundamental difference in the management of the ends of the intestinal segments between which the stoma will be created in a side-to-side or end-to-end anastomosis. When performing a side-to-side anastomosis, the stump is formed in one of two ways: by ligation followed by invagination into a purse-string suture (for peritonealization) or by closing the intestinal lumen with a two-row suture. An isoperistaltic arrangement of the stumps in a side-to-side anastomosis is essential, and the specifics of its execution (using elastic intestinal clamps or, preferably, stay sutures) are reviewed.

When performing an end-to-end anastomosis, a stump is not formed; however, the clamp used for resection is applied obliquely to increase the diameter of the segments to be sutured. In addition, a continuous suture should be avoided during this anastomosis, as it may lead to stricture of the stoma. The remaining steps for creating both anastomoses are similar.

A side-to-side anastomosis should begin by placing a interrupted seromuscular or seroserous Lambert silk suture closer to the mesentery (Fig. 55). An incision of the intestine, 7-8 cm in length, is made on the facing surfaces, slightly exceeding the diameter of the bowel, and is placed 0.5 cm away from the first row of sutures. A second row of catgut sutures is applied through all layers using the Joll or Pirogov method for the posterior Lips, and the Schmieden method for the anterior lips of the anastomosis. Upon completion of the anastomosis, its patency must be verified.

Fig. 55. Intestinal suture:

I - Joll method: 1 - serosa; 2 - muscular layer; 3 - mucosa; II - Lembert method; III - Albert two-layer suture; IV and V - closure of an intestinal wound. Traction sutures are applied to convert a longitudinal wound into a transverse one, followed by an inverting Schmieden suture.

An end-to-end stoma is created in a similar manner: the Joll suture is used for the inner lips, and the Schmieden suture for the anterior lips. The operation is completed by placing a circular seroserous suture.

5. Self-Assessment Materials

A. Self-Assessment Tasks

Test No. 1

To place an intestinal suture, the surgeon used a Hegar needle holder. Which of the surgeon's fingers should be placed in the rings of this instrument to ensure its optimal grip and stability in the hand?

a. 1st and 2nd

b. 1st and 3rd

c. 1st and 4th

d. 1st and 5th

e. 2nd and 4th

Test No. 2

The surgeon uses the jejunum to create an anastomosis. How is this section of the intestine typically covered by the Peritoneum?

a. Intraperitoneally

b. Mesoperitoneally

c. Extraperitoneally

d. Retroperitoneally

e. Initially intra-, then extraperitoneally.

Test No. 3

Using a piercing needle, the surgeon places an interrupted single-layer seromuscular suture incorporating the submucosa on the outer edge of the anastomosis. The knots are tied into the lumen of the hollow organ. The distance between the stitches is 1 cm. Which requirement for intestinal sutures will be violated?

a. Asepsis

b. Hemostatic property

c. Airtightness

d. Organ patency

e. Relative automaticity

Test No. 4

A surgeon used a single-row interrupted sero-serous suture to form an anastomosis. What is the name of this suture?

a. Pirogov's

b. Schmieden's

c. Lembert's

d. Lembert's

e. Czerny's

Test No. 5

During small bowel resection, the surgeon created a side-to-side intestinal anastomosis using double-row sutures. Which wall of the anastomosis should the surgeon start forming first?

a. Anterior

b. Posterior

c. Superior

d. Inferior

e. It does not matter

B. Self-Assessment Tasks

Task 1. When suturing a longitudinal wound of the small intestine, the surgeon applied a single row of sero-serous sutures and, after drying the peritoneal cavity, closed the abdominal wall wound layer by layer. Are there any errors in the surgeon's actions?

Task 2. During surgery for an incarcerated indirect inguinal hernia, a loop of the small intestine showing signs of necrosis was found in the hernia sac. After resection of the necrotic segment of the intestine, due to a discrepancy in the lumen diameter of the afferent and efferent PARTS OF THE loop, the surgeon performed a side-to-side entero-enteral anastomosis, with the stoma size twice exceeding the width of the corresponding intestinal loop. In the postoperative period, intestinal obstruction developed in the area of the anastomosis. What are the possible causes of this complication, and how can it be prevented?

Task 3. When resecting the small intestine followed by an end-to-end entero-enteral anastomosis, the surgeon transversely transected the intestinal loop. What is the surgeon's error, and what complications can be expected after creating the anastomosis?

References

Basic

1. Operative Surgery and Topographic Anatomy; edited by M.S. Skrypnikov. — Kyiv: Vyshcha Shkola, 2000. — P. 312-332.

2. Operative Surgery and Topographic Anatomy; ed. by M.P. Kovalsky. — Kyiv: Medytsyna, 2010. — P. 237-272.

Supplementary

1. Kovanov V.V. Operative Surgery and Topographic Anatomy / V.V. Kovanov. — M., 2001. — P. 334-364.

2. Operative Surgery and Topographic Anatomy; ed. by M.S. Skrypnikov. — Poltava, 2001. — P. 202-246.

3. Operative Surgery and Topographic Anatomy; ed. by K.I. Kulchytsky. — K., 1994. — P. 207-240.

4. Elizarovsky S.I. Operative Surgery and Topographic Anatomy / S.I. Elizarovsky, R.N. Kalashnikov. — M., 1979.

5. Matyushin I.F. Introduction to the Course of Operative Surgery and Topographic Anatomy / I.F. Matyushin. — Gorky, 1976.

6. Tomashuk I.P. Guide to Operative Technique for Beginner Surgeons / I.P. Tomashuk, I.I. Tomashuk. — Kyiv: European University Press, 2001. — 860 p.

7. Frauchi V.Kh. Course of Topographic Anatomy and Operative Surgery / V.Kh. Frauchi. — M., 1976.