- What types of anastomoses are used in surgery?
- What should an anastomosis be? Description and characterization of the essence of the anastomosis Description of the
In anatomy, anastomoses are called anastomoses of large and small vessels to enhance blood supply to the bodyor its support for thrombosis of one of the directions of the blood flow. An anastomosis of the intestine is an artificial joint created by a surgeon, two ends of the intestinal tube or gut and a hollow organ( stomach).
The purpose of creating such a structure:
- ensuring the passage of the food lump to the lower divisions for the continuity of the digestive process;
- formation of a workaround with a mechanical obstruction and impossibility of its removal.
Operations can save a lot of patients, provide them with very good health or help to prolong life in the case of an inoperable tumor.
What kinds of anastomoses are used in surgery?
The connected parts distinguish an anastomosis:
- esophagogus - between the end of the esophagus and the duodenum bypassing the stomach;
- gastrointestinal( gastroenteroanastomosis) - between the stomach and intestine;
The third option is an indispensable component of most intestinal operations. Among this species, anastomoses are distinguished:
- small intestine,
- small intestine,
- large intestine.
In addition, in abdominal surgery( a section associated with operations on the abdominal organs) it is accepted, depending on the technique of performing the connection of the leading and leading sites, to distinguish certain types of anastomoses:
- end to end;
- end to side;
- side to end.
What should an anastomosis be?
The created anastomosis should correspond to the expected functional purposes otherwise there is no sense to operate the patient. The main requirements are:
- providing a sufficient width of the lumen so that the constriction does not interfere with the passage of the contents;
- absence or minimal intervention in the mechanism of peristalsis( contraction of the muscles of the intestine);
- complete sealing of seams providing connection.
If one specialist can not decide how to deal with the patient, the
is being collected. The surgeon is important not only to determine what kind of anastomosis will be imposed, but also how to seam the ends. This takes into account:
- intestinal tract and its anatomical features;
- presence of inflammatory signs at the site of surgery;
- intestinal anastomoses require a preliminary assessment of the viability of the wall, the doctor carefully examines it by color, the ability to contract.
The most common are classic seams:
- Gum or nodal - needle punctures are done through the submucosal and muscle layers without grasping the mucous;
- Lambert - the serous membrane( external to the intestinal wall) and the muscle layer are stitched.
Description and characterization of the essence of anastomosis
The formation of an anastomosis of the intestine is usually preceded by the removal of the part of the intestine( resection).Next, it is necessary to connect the leading and outgoing ends.
Used to stitch two identical segments of the large intestine or thin. It is performed with a two- or three-row seam. It is considered the most beneficial from the point of view of observing anatomical features and functions. But it's technically difficult to accomplish.
The condition of the connection is the absence of a large difference in the diameter of the areas to be compared. The end, which is smaller in the lumen, is cut for full compliance. The method is used after resection of the sigmoid colon, in the treatment of intestinal obstruction.
The anastomosis posterior wall is formed first, then the anterior
end-to-side anastomosis. The method is used to connect parts of the small intestine or on one side - thin, on the other - thick. Usually, the small intestine is sutured to the side of the wall of the large intestine. Provides 2 stages:
- At the first stage form a dense stump from the end of the gut. The other( open) end is applied to the intended site of the anastomosis on the side and is sewn along the back wall by the Lambert seam.
- Then, an incision is made along the esophagus along the length equal to the diameter of the leading site and the front wall is stitched with a continuous seam.
It differs from the previous versions by preliminary "blind" closing with a double-row seam and forming stumps from the connected intestinal loops. The end, above the stump located, the lateral surface is connected to the underlying area by the Lambert seam, which is twice as long as the diameter of the lumen. It is believed that the technical implementation of such an anastomosis is the easiest.
Can be used both between homogeneous parts of the intestine, and for communication of dissimilar sites. Main indications:
- need for resection of a large area;
- risk of overstretch in the anastomosis zone;
- small diameter of the connected sections;
- formation of an anastomosis between the small intestine and stomach.
The advantages of the method include:
- no need to sew mesentery of different sites;
- tight connection;
- guaranteed prevention of intestinal fistula formation.
With side-to-side anastomosis, the pre-creation of the stumps refers to the drawbacks of the
If this type of anastomosis is selected, it means that the surgeon suggests sewing the end of the organ or intestine after resection into the created hole on the lateral surface of the resulting intestinalloops. It is often used after resection of the right half of the large intestine to connect the small and large intestine.
The connection may have a longitudinal or transverse( more preferred) direction with respect to the main axis. In the case of transverse anastomosis, less muscle fibers intersect. This does not disturb the wave of peristalsis.
Prevention of Complications
Complications of anastomoses can be:
- seam divergence;
- inflammation in the anastomosis zone( anastomosis);
- bleeding from damaged vessels;
- formation of fistulous passages;
- formation of constriction with intestinal obstruction.
To avoid adhesions and ingestion of intestinal contents into the abdominal cavity:
- the site of the operation is covered with napkins;
- incision for stitching ends is carried out after clamping the intestinal loop with special intestinal pulp and extruding the contents;
- sutures the incision of mesenteric margin( "window");
- palpation is determined by the patency of the created anastomosis before the operation is completed;
- in the postoperative period, antibiotics of a wide spectrum are prescribed;
- in the course of rehabilitation necessarily includes diet, exercise therapy and breathing exercises.
Modern methods for the protection of anastomosis
In the near postoperative period, the development of anastomozitis is possible. Its cause is considered:
- an inflammatory response to suture material;
- activation of a conditionally pathogenic intestinal flora.
For the treatment of subsequent cicatricial narrowing of the esophageal anastomosis, an endoscope is used with polyester stents( expanding tubes supporting the walls in the expanded state).
For the purpose of strengthening the sutures in abdominal surgery, autografts( filing of own tissues) are used:
- from peritoneum;
- oil seal;
- fatty pendants;
- mesenteric flap;
- serous-muscular flap of the stomach wall.
However, many surgeons restrict the use of the omentum and peritoneum on the feeding stem with the blood supply vessel only to the last stage of colon resection, since these methods are considered to be the cause of postoperative suppurative and adhesive processes.
The process of anastomosis application - laborious work
Various protectors with drug filling for suppression of local inflammation are widely approved. These include glue with biocompatible antimicrobial content. In it for the protective function included:
- cellulose ethers;
- polyvinylpyrrolidone( biopolymer);
And also antibiotics and antiseptic:
The surgical glue becomes hard when hardened, so anastomosis may be narrowed. More promising are gels and solutions of hyaluronic acid. This substance is a natural polysaccharide, is released by organic tissues and some bacteria. It is part of the intestinal cell wall, therefore it is ideal to accelerate the regeneration of anastomotic tissues, does not cause inflammation.
Hyaluronic acid is included in biocompatible bioresorbable films. A modification of its compound with 5-aminosalicylic acid is suggested( the substance belongs to the class of non-steroidal anti-inflammatory drugs).
Intestinal pulp is applied along the longitudinal axis, it is possible to safely isolate the area of
needed for resection. Postoperative atopic constipation
Especially coprostasis( stool stasis) occurs in elderly patients. Even an inactive bed rest and a diet in them disrupt the function of the intestines. Constipation may be spastic or atonic. The loss of tonus is removed as the diet expands and physical activity increases.
To stimulate the intestines on 3-4 days, a cleansing enema is prescribed in a small volume with hypertonic saline solution. If the patient needs a prolonged exclusion of food intake, then use Vaseline oil or Mukofalk.
In case of spasmodic constipation it is necessary:
- to relieve pain with medications with analgesic action in the form of rectal suppositories;
- to lower the tone of the sphincter of the rectum with the help of preparations of the spasmolytic group( No-shpy, Papaverina);
- for softening of fecal masses make microclysters from warm vaseline oil on a solution of furacilin.
Secretion-anti-absorbent are considered:
- senna leaves,
- buckthorn bark,
- rhubarb root,
- castor oil,
Osmotic effect is possessed by:
- Glauber and Karlovy Vary salt;
- magnesium sulfate;
- lactose and lactulose;
Laxatives, increasing the amount of fiber in the large intestine - Mukofalk.
Early treatment of anastomositis
For the removal of inflammation and swelling in the joint zone, the following are prescribed:
- antibiotics( Levomycetin, aminoglycosides);
- for localization in the rectum - microclysters from warm furacilin or by installing a thin probe;
- soft laxatives based on vaseline oil;
- patients are recommended to take up to 2 liters of liquid, including kefir, mors, kissel, compote to stimulate the passage of intestinal contents.
If an intestinal obstruction is formed
Occurrence of an obstruction can cause swelling of the anastomosis zone, cicatricial narrowing. In the case of acute symptoms, repeated laparotomy( cut in the abdomen and opening of the abdominal cavity) is performed with the elimination of pathology.
With chronic obstruction in the distant postoperative period, intensive antibiotic therapy is prescribed, the removal of intoxication. The patient is examined for the purpose of resolving the issue of the need for surgical intervention.
Any complications require treatment
Sometimes complications are associated with inept or under-qualified operation. This leads to excessive tension of the suture material, superfluous superposition of multi-row sutures. At the junction, fibrin falls and mechanical obstruction is formed.
Anastomoses of the intestine require compliance with the technique of surgery, careful consideration of the condition of the tissues, the skill of the surgeon. They are imposed as a result of surgical intervention only in the absence of conservative methods of treating the underlying disease.