Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy.
Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA.
Colorectal Dis. 2017 Oct;19(10):O372-O376. doi: 10.1111/codi.13856.
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°.
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.
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.
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.
侧侧吻合的肠切开术的近侧边缘是发生漏液的高风险部位。已经描述了几种方法来克服这一脆弱性。腔内吻合术（ICA）的技术挑战是在组织和器械之间重新形成类似于开放吻合术的角度。缝线和持针器之间的轴至关重要，这个角度应该小于 45°。
由于肠切开术的环之间的空间狭窄以及吻合术的深度，肠切开术的叉状缝合很困难。通常的技术是右手缝合，“外进内出，内进外出”，先缝合结肠边缘，再缝合小肠。缝合错位的风险（例如“外进外出”或“外外”）与开放手术相似，但由于直持针器，第二口缝合具有挑战性。这可能导致角的不对称闭合，导致肠侧的角度略大，术后潜在漏液/瘘管。为了平衡这个问题而旋转小肠环，可能会导致吻合钉线撕裂。其原理是，从反手缝合开始，并先缝合小肠边缘，可以实现必要的锐角咬合。随后，用右手安装针，缝合结肠边缘，也可以实现锐角咬合。
我们的新技术，称为“反手，从左到右缝合”技术，旨在在腹腔镜下实现回肠和结肠边缘的对称接近，并且能够最佳地闭合肠切开术的最深端。在 10 例患者中使用这种缝合技术，可以避免在这个角度处留下开口，并且/或者在闭合肠切开术的最深顶点时避免潜在的技术陷阱。
这里描述的“反手，从左到右”缝合可以实现肠切开术近端边缘的适当角度闭合，并在侧侧 ICA 中安全地接近肠切开术的角。
