A 6-year-old boy experienced life threatening shock, his CT scan showed large amount of ascites, bowel wall thickening and poor or absent enhancement of the strangulated bowel segment, showing gangrenous bowel on surgical exploration. True about anastomosis is
(D) Should be Done by single layer by taking submucosa[?]Diagnosis is of congenital IH with strangulated small bowel with gangrenous small bowel.Transmesenteric hernia was the most common type in older children as well as in neonates.IH results from incomplete closure of surgically created mesenteric defects, and usually acquired resulting from previous abdominal surgery especially Roux-en-Y anastomosis.Anastomosis should be done by single layer seromuscular lembert sutures.The Lambert suture generally is used in abdominal surgery. It is an inverting suture, that can be either continuous or interrupted, used to join two segments of an intestine without entering the lumen (the inner channel through which stomach contents flow).Methods of Intestinal AnastomosisSutured anastomosisStapled AnastomosisOther*. Hand sewn*. Continuous or interrupted*. Absorbable sutures*. Or non-absorbable sutures*. Orthodox two layer closure*. Innovative single layer use*. Sero-submucosal apposition* Side to side with linear device (GIA 60)* End to end with cicular device (CEEA)*. Mainly academic value*. Less frequent use*. Weaker evidence*. Examples include*. Compression rings*. Tissue adhesives*. Metal wires*. Magnets Single Layer Anastomosis: An interrupted seromuscular suture, with absorbable thread. The submucosal layer is strong & the blood supply is only minimally damaged.Double Layer Anastomosis:An inner continuous absorbable suture, with stitching of all layers.An outer, seromuscular, interrupted non-absorbable suture.Serosa apposition & mucosa inversion, the inner layer has a hemostatic effect, but the mucosa is strangulated. Connell stitch - continuous.Other Options[?]Principles of Anastomosis:No disparity between the two ends of lumen. If one end is narrower it can be enlarged by 'fish mouthing' of the end.To prevent leakage of contents & to steady the two ends, non-crushing clams or stay sutures to be applied across the gut.Three types of suture can be used for anastomosis of the gut:-All coat stitches: All layers of the gut are taken. Advocated by Halsted.-Extra-mucosal or sero-submucosal technique: All layers are included except mucosa. Submucosa is the strongest layer, as it contains plenty of collagen tissue.-Sero-muscular stitch: Bites taken through the serosa & part of the muscular layer. Also known as Lembert stitch. Used as a second layer to strengthen the first layer.[?]Suture Material:Two-layer anastomoses are made with an inner layer of absorbable suture & outer layer of non-absorbable sutures. Single layer anastomoses are usually made with non-absorbable materials.Polyglycolic acid & Polyglactin most popular absorbable suture material.Non-absorbable sutures on the mucosal aspect of gut provoke a significant foreign body reaction & granuloma formationThis is of little practical significance in small & large intestinal anastomoses but in gastric mucosa may result in ulceration & clinical symptoms.Theoretically mono-filament sutures like nylon or polypropylene may cause less tissue reaction than braided sutures, but the difference in the intestine appears to be relatively minor & the mono-filament sutures have inferior handling qualities.Most surgeons prefer braided silk because of good handling.Size of the gauge used for anastomoses is use 2-0/3-0 in adult surgery as the finer sizes will have tendency to cut through.[?]Surgical Intervention Urgent Laparotomy:Gangrenous small intestine or Right colon = Resection & primary anastomosis Infarction of large intestine 'rare' due to embolization of middle colic artery. Resection of transverse colon with exterioorization 'Paul mickulicz's techniqueSecond look operation in primary anastomosis after 24-48 hours:-If further pathology clinically detected. To check viability of intestine.Avoid primary anastomosis in case of:-Friable tissue in peritonitis. Bad general condition. Doubtful viability of remaining intestine.-So in these cases do 2 barrel colostomy till general & local condition improve.
Should be done by continuous layers as it takes less time
Should be done with catgut
Should be done by single layer seromuscular Lambert sutures
Should be done by Single layer by taking submucosa
Small & Large Intestine