Page 586 - WSAVA2018
P. 586

 25-28 September, 2018 | Singapore
There is considerable controversy regarding specific suture pat¬tern for use in small intestinal surgery. Everting, inverting, and ap¬positional suture patterns have been used experimentally and clinically for suturing enterotomies and anastomoses. Appositional patterns are recommended as they cause little lumen compromise postoperatively.
Everting: Everting patterns (i.e., horizontal mattress) have been shown to encourage adhesions and result in lumen stenosis. This technique is NOT recommended. The everting technique is not to be confused with the mild eversion of mucosa that occurs in the appositional techniques described below.
Inverting: In small animals adequate lumen diameter is an important consideration with any technique. Inverting patterns result in substantial lumen compromise of the small intestine and are NOT recommended in dogs and cats.
Apposition: Anatomic apposition of individual layers of the bowel wall (i.e., mucosa, submucosa, muscularis, and serosa) result in primary intestinal healing. This technique is superior to inverting or everting techniques because apposition of intestinal margins eliminates lumen compromise. This is the authors preferred technique for suturing all hollow viscus organs in the abdominal cavity. Suture patterns of choice include:
1) Simple interrupted apposing. This technique involves suturing all layers of the intestinal wall and tying the knots on top of the serosa to approximate cut edges. The sutures should be tied tight enough to effect a watertight seal, yet not so tight as to blanch the tissue and cause ischemia of intestinal margins. This technique is simple, fast, reliable, and does not result in lumen compromise.
2) Simple continuous apposing. This technique is
similar to the simple interrupted appositional technique however, a continuous suture pattern is used rather than an
interrupted pattern. Advantages include faster anastomosis, equal suture tension over the entire anastomosis, airtight-watertight seal, and mucosal eversion is minimized. This is the authors preferred suture pattern for suturing all hollow viscus organs in the abdominal cavity.
INTESTINAL ANASTOMOSIS: Intestinal anastomosis is indicated for resection of nonre-ducible intussuscep¬tion, necrotic bowel wall secondary to complete intestinal obstruction, intes¬tinal volvulus, stricture secondary to trauma, linear foreign body with multiple perforations, and intestinal neoplasia (e.g., leiomyoma, leiomyosarcoma, adenocarcinoma).
After a complete abdominal exploration, the affected length of bowel is delivered from the peritoneal cavity
and isolated with the use of moistened laparotomy pads and crib towels. If possible, the intestinal anastomosis should be performed on a water resistant surface (e.g., plastic drape, crib towel) to prevent ‘strike’ through contamination.
Once the level of resection has been determined,
the appropriate mesenteric vessels are identified and ligated, and the portion of intestine to be resected is isolated by clamping the bowel at a 60° angle away from the mesenteric border. This angle ensures adequate blood supply to the antimesenteric border.
Everted mucosa: Occasionally when the segment of intestine to be removed is amputated mucosa ‘everts’ from the cut edge of the intestinal wall making it difficult to visualize the cut edge of the serosa. If this occurs it is ‘highly’ recommended to excise the everted mucosa to enable the surgeon to easily visualize the cut edge of the intestinal serosa. It is vital that the surgeon engage at least 3 – 4 mm of intestinal wall with each suture
to guarantee adequate bites in the collagen laden submucosa.
Bowel lumen diameters: In cases where the oral end of the bowel is dilated and the aboral end is normal size, several options exist to create intestinal lumens of equal diameter:
1) Increase the angle of resection on the smaller diameter segment of bowel (i.e., aboral segment). This will increase the orifice size by 5-10 mm depending upon bowel diameter (e.g., dog vs cat).
2) In larger lumen size discrepancies the antimesenteric border of the smaller diameter stoma can be in¬cised longitudinally to enlarge the lumen diameter.
3) An end to side anastomosis can be performed by closing the larger diameter stoma of the in¬testinal resection with a single layer continuous apposing suture pattern then anastomosing the smaller diameter segment of bowel to an appropriate size enterotomy made in the antimesenteric border of the larger diameter segment of bowel.
4) The larger diameter segment of bowel can be made smaller in diameter by suturing its cut edge until its lumen is equal in size to the smaller diameter intestine (this technique is often used for subtotal colectomy in cats).
Intestinal Anastomosis Technique:
See the DVD for a detailed video description of this technique (www.videovet.org).
When suturing an anastomosis, atraumatic handling of bowel wall and perfect anatomic apposition of incised margins is important. It is recommended to
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43RD WORLD SMALL ANIMAL VETERINARY ASSOCIATION CONGRESS AND 9TH FASAVA CONGRESS









































































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