A novel technique for enterotomy closure in stapled laparoscopic intracorporeal anastomosis

S. di Saverio, A. Birindelli, E. Segalini, S. Todero, R. A. Botusan, M. Novello, S. Kwan, A. Biondi

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3 Citations (Scopus)

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.

Original languageEnglish
Pages (from-to)O372-O376
JournalColorectal Disease
Volume19
Issue number10
DOIs
Publication statusPublished - 1 Oct 2017

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di Saverio, S., Birindelli, A., Segalini, E., Todero, S., Botusan, R. A., Novello, M., ... Biondi, A. (2017). A novel technique for enterotomy closure in stapled laparoscopic intracorporeal anastomosis. Colorectal Disease, 19(10), O372-O376. https://doi.org/10.1111/codi.13856