Bowel Anastomosis

Evolution of the technique

and the modern practise

Dr Mohan Samarasinghe
Consultant Surgeon in Gastroenterology
 Ana stomo sis

Without Opening/Mouth Status

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Prior to the nineteenth century, intestinal
surgery was limited to exteriorisation

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Systematic studies on intestinal suturing really
began in the early nineteenth century. In 1812,
Travers studied the healing of hand sewn
anastomoses in rabbits.

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 Attempts at closing a bowel opening
• Glover's Suture - Mucosa to mucosa continuous - ends brought through
the anterior abdominal wall, removed later

• Ledran's Suture - Mucosa to mucosa, tied multiple sutures on the same

side and twisted both suture ends together to pucker up the wound

• Bertrandi's suture - The lips of the wound being approximated with

continuous suture. no invagination

• Jobert’s suture - Interrupted sutures to intussuscepted the proximal end

to distal end

• Ramdohr's lnvagination - Invagination of the two ends by stitching them

together by two or three points of the interrupted suture

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Glover's Suture
Mucosa to mucosa continuous - ends brought through
the anterior abdominal wall, removed later

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Ledran's Suture
Mucosa to mucosa, tied multiple sutures on the
same side and twisted both suture ends
together to pucker up the wound
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Bertrandi's suture
The lips of the wound being approximated with
continuous suture. no invagination

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Jobert’s suture
Interrupted sutures to intussuscepted the
proximal end to distal end
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Ramdohr's lnvagination
Invagination of the two ends by stitching them together by
two or three points of the interrupted suture

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 Antoine Lembert (1802–1851)
Antoine Thomas Alfred Étienne
Lembert , 1802–1851, Surgeon at
Hôtel Dieu, Paris, France.

Study on intestinal suture

with a description of a
new procedure for
performing this surgical
operation
Lembert A. Repertoire general
d'anatomie et de physiologie
pathologique et des cliniques
chirurgicales. Vol. 2. 1826:100-7
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 Lembert Suture
• He noted that the muco-mucosal sutures are of poor
quality and should be abandoned in favor of
sero-serous sutures.
• The originality of Lembert is to make a musculo-serous
interrupted suture with separate points with leaning of
the serous surfaces and inversion of the edges of the
wound in the intestinal lumen.
• This suture is sometimes called far-near-near-far
depending on the point of penetration of the needle
relative to the edge of the wound. ? vertical mattress

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Lembert Suture

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 Lembert's modified by Dupuytren
• Same as the lembert’s suture but made
continuously

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 Lembert's modified by Jobert
• Sutures traverse the entire thickness of the
bowel wall

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 Lambert’s modified by Czerny (1881)

• Mucosa united with the first layer and then

overlying Lembert’s stitch

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 Lumber’s method modified by Kocher
• Same configuration as
Czerny’s modification
• Utilised a two-layer
anastomosis
• First a continuous all-layer
suture using catgut
• Then an inverting continuous
(or interrupted) sero-
muscular layer suture using
silk
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 Modern day double layer
• Same configuration as
Czerny’s modification of
the Lembert’s suture
• Utilises a two-layer
anastomosis
• Now uses synthetic
sutures with minimal
tissue reactions
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 Connell (1892)
• Continuous inverting suture
• Horizontal mattress suture
• Cushing modified
it to sero-muscular

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William Stewart Halsted (1852 -1922)

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Halstead’s plain quilt single
layer
All passes through bowel wall are catching the
submucosa

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 Halstead’s ➔ Dudley ➔ Matheson
• Halsted’s paper in 1887 emphasised the hitherto overlooked
importance of the submucosa in terms of suture placement
• Dudley in Aberdeen used a single layer technique in 1958 in
ileo-colic anastomosis
• Matheson in 1976 devised a technique described as ‘single-layer
appositional sero-submucosal anastomosis’.
• The theoretical advantages of a single over a two layer are more
rapid and reliable healing because of minimal interference with
vascularity and more accurate apposition of the divided bowel.

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 Modern Single Layer : Sero-Submucosal

• Anatomical layers
approximation
• Good tissue
holding strength
• Minimal tissue
necrosis

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 Factors to Consider
• Prevention of spillage - Clamping / decompress
• Avoid clamping or suturing mesenteric vessels
• Good Lighting
• Maintenance of good perfusion and tissue
oxygenation (BP and Sat)
• Assessment of Viability of bowel
• Blood supply- bright red bleeding from cut edge

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 Negotiating caliber
• Oblique division
• Cheatling
• Side-to-side
• End-to-side
• Closer bites from the narrow
side, wider bites from the
wider side
• Partial closure of the wider
side
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 Tension Free
Tension causes ischaemia
and structural failure

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 Appropriate Sutures
• Hydrolysing (Absorbable)
• Non-reacting / inert (Non-absorbable)
• Good knot security
• Some elasticity

Vicryl (Polygalactin 910)

PDS (Polydiaxanone)
Ethibond (Polyester)
Polypropylene
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 Edges
• Neat (straight sharp cut)
• Haemostasis
• Trim excess mucosa
• Inverting
• Adequate patency

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 Closure of Mesenteric Defect
• Interrupted
• Absorbable
• Only serosa (Save mesenteric vessels)
• Adequately spaced to prevent creating
multiple small holes in the mesentery

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 Physiology of bowel healing
• Early phase (0–4days): There is an acute
inflammatory response, but no intrinsic
cohesion.
• Fibroplasia (3–14days): Fibroblast proliferation
occurs with collagen formation.
• Maturation stage (>10 days): This is the period
of collagen remodelling, when the stability and
strength of the anastomosis increase

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 References
• Travers B. An inquiry into the process of nature in repairing injuries of the intestines: illustrating the
treatment of penetrating wounds, and strangulated hernia. London: Longman, Hurst, Rees, Orme, and
Brown, 1812.
• Senn N. Enterorrhaphy; its history, technique, and present status. JAMA 1893;21:215–35.
• Lembert A. Nouveau procede d'enterorraphie. Repertoire General d'Anatome et de Physiologie
Pathologique 1826;2:3.
• Lembert A. Nouveau procede d'enterorraphie Arch Gen Med 1827;13:234.
• Czerny. Quoted by Jaffee K. Uber darmresection bei gangranosen hernien. Sammlung Klinischer
Vorträge 1883;201:1689–1702.
• Connell ME. An experimental contribution looking to an improved technique in entorrhaphy, whereby
the number of knots is reduced to two, or even one. Med Rec 1892;42:335–7.
• Halstead WS. Circular suture of the intestine—an experimental study. Am J Med Sci 1887;94:436–61.
• Reid MR. Some considerations of the problems of wound healing. N Engl J Med 1936;215:753.
• Carrel A. The treatment of wounds. JAMA 1910;55:2148–50.
• Howes EL, Sooy JW, Harvey SC. The healing of wounds as determined by their tensile strength. JAMA
1929;92:42–5.
• Matheson NA, Irving AD. Single layer anastomosis in the gastrointestinal tract. Surg Gynecol Obstet
1976; 143: 619-24.

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Thank you