A novel technique for enterotomy closure in stapled laparoscopic intracorporeal anastomosis

作者：di Saverio, S.^*; Birindelli, A.; Segalini, E.; Todero, S.; Botusan, R. A.; Novello, M.; Kwan, S.; Biondi, A.

来源：Colorectal Disease, 2017, 19(10): O372-O376.

DOI：10.1111/codi.13856

• Laparoscopic colorectal surgery
• intracorporeal anastomosis
• laparoscopic suturing
• right colectomy
• ileo-colic anastomosis
• surgical technique education

Aim 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 degrees.
Method 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.
Results 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.
Conclusion 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.

• 出版日期2017-10