Classification of main types of connections
In surgical practice, there are four basic options for forming anastomoses between segments of the gastrointestinal tract:
- End-to-end — direct connection of the cut ends of hollow organs using a two- or three-row suture.
- Side-to-side — a method in which the stumps of the organs are closed tightly, and the loops are positioned isoperistaltically.
- End-to-side — an option where the cut end of one organ is sutured to the lateral wall of another.
- Side-to-end — connection of the lateral surface of the proximal segment to the end of the distal segment.
End-to-end anastomosis and its features
This technique is considered the most physiological because it restores the natural course of the intestine.
- Execution technique: To prevent luminal narrowing in the anastomotic area, the intestine is transected obliquely, excising more of the free margin.
- Limitations: Specialists do not recommend using this method when joining intestinal tubes that differ significantly in diameter, such as the small and large intestine.
Advantages of side-to-side anastomosis
When creating this connection, the stumps of the sutured segments are closed tightly, and the loops themselves are placed isoperistaltically, connecting via their lateral surfaces.
The main advantage of this approach is the absence of the risk of luminal narrowing. The width of the formed anastomosis is not limited by the initial diameter of the intestines and can be freely adjusted by the surgeon.
Indications for end-to-side and side-to-end connections
Various anatomical situations dictate the need for combined approaches:
- End-to-side: Indispensable when working with GI tract segments of different diameters. Clear examples include gastric resection (when the gastric stump is sutured into the side of the small intestine) or connecting the small intestine to the lateral wall of the large intestine.
- Side-to-end: Used significantly less often than other types. Examples include Roux-en-Y gastroenterostomy or ileotransversostomy.
Rules for naming intestinal anastomoses
In medical terminology, there is a strict rule for constructing the names of anastomoses: the organ located more proximally is always designated first, and the one located distally is designated second.
Example: An ileotransversostomy can mean the connection of the end of the ileum to the lateral surface of the transverse colon (end-to-side) or the connection of their lateral surface to the end (side-to-end).
Briefly: answers to topical questions
Which eponymic intestinal suture types are used to form the inner and outer rows of an anastomosis?
Schmieden's suture is used to form the inner row of the intestinal anastomosis, and a seromuscular suture without an eponym is used for the outer row.
- Schmieden's suture — a continuous inverting (or lockstitch) suture applied through all layers to suture the anterior lips.
- Seromuscular suture — an interrupted suture for the outer row, capturing only the serous and muscular layers.
What surgical methods exist for closing the intestinal stump during a side-to-side anastomosis?
When performing a "side-to-side" anastomosis, the intestinal stumps are closed tightly.
The method of intestinal stump formation described in the sources:
- Doyen's method — performed for the afferent and efferent ends: the intestine is ligated with a catgut ligature beneath a clamp, a purse-string suture is applied 1.5 cm away from the ligation site, the stump is invaginated while tightening the purse-string suture, and a row of interrupted seromuscular sutures is placed over the purse-string suture.
- Purse-string suture — used for invaginating the stump; when tightened, the stump is embedded deep inside.
- In "side-to-side" enteroenterostomy, invagination of the ligated stump into a purse-string suture is also described.
What early and late complications are characteristic of intestinal anastomoses?
The cited sources do not contain a direct classification of intestinal anastomosis complications into early and late.
The following adverse conditions associated with anastomoses or intestinal sutures are mentioned separately in the sources:
- Narrowing of the anastomotic lumen — in an end-to-end anastomosis, to prevent narrowing, the intestine is transected obliquely; this type of anastomosis is not recommended when joining intestines of different diameters.
- Suture failure — for the anastomosis during a Billroth I gastric resection, a vulnerable spot is indicated: the "junction" of three sutures in the upper part of the anastomosis, where suture cutting through and failure are possible.
- Intestinal wall ischemia and suture failure — described as a consequence of unacceptable enterotomy through the anterior lip of the anastomosis during relaparotomy.
- Anastomotic strictures — mentioned in sources as a variant of jejunal or ileal strictures after previous resections.
Proximal is first in the name (closer to the stomach), distal is second (closer to the exit).
Class and exam questions
Which anastomosis is considered the most physiological?
End-to-end anastomosis, as it provides a direct connection of the ends of hollow organs.
Why is an end-to-end anastomosis not recommended for intestines of different diameters?
This can lead to technical difficulties and a mismatch in the lumen of the anastomosis, which is why an end-to-side connection is chosen in such cases.
How are the intestinal loops positioned when creating a side-to-side anastomosis?
The intestinal loops are positioned strictly isoperistaltically, and their stumps are closed tightly.
Which organ is indicated first in the name of an anastomosis?
The organ located more proximally along the course of the gastrointestinal tract is always indicated first.
What else to study on this topic
- Multi-row suture in the formation of a direct anastomosis
- Technique of oblique intestinal transection for the prevention of stenosis
- Anatomical rationale for the isoperistaltic arrangement of loops
- Features of gastric resection with the formation of anastomoses
- Principles of performing an ileotransversostomy
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