Anastomotic Construction

Abstract

Anastomotic construction represents a fundamental and essential skill restoring intestinal continuity and preserving bowel function and continence.• It encompasses a broad range of methods and configurations and can be performed utilizing a spectrum of operative platforms. • While anastomosis may be a heterogeneous endeavor, consistent fundamental principles must be preserved in all its forms. • Stapling technologies represent a challenge for surgeon knowledge and understanding their use in clinical practice given the numerous innovations and specific tissuedevice interactions. • Colonic mobilization techniques bringing bowel into proximity to the distal limb while preserving blood supply represents an essential and critical skill for anastomotic construction. Surgeons must be familiar with advanced techniques for mobilization to achieve anastomosis.

Ileocolic Anastomoses

“…Several different features of hand sewn bowel anastomoses have been considered including suture material, continuous or interrupted suture, single or multilayer closures, and tension on the anastomosis. 1 A large systematic review of techniques for hand sewn colorectal anastomoses, including ileocolic anastomoses, concluded that “a single-layer continuous technique using inverting sutures with slowly absorbable monofilament material” was associated with lowest risk of postoperative complications. 2 One weakness of hand sewn anastomoses is a heavy dependence on the technical expertise of the surgeon and ability to reproduce results consistently.…”

“…Staplers not only rely on tissue compression and multiple rows of staples spaced to adequately seal the bowel but also allow for consistent perfusion. 1 While some early studies suggested that stapled anastomoses carried higher risk of anastomotic leak when compared with hand sewn techniques, 3 4 others have found decreased anastomotic leak rates in patients with stapled anastomoses. 5 6 A 2019 large multicenter study of over 4000 patients undergoing open right hemicolectomy found no significant difference in leak rates between patients with hand sewn and stapled ileocolic anastomoses.…”

“…However, more isoperistaltic anastomoses are being performed, particularly in the context of minimally invasive surgery. 1 Proponents of isoperistaltic ileocolic anastomoses highlight that these anastomoses typically require less mobilization of the bowel to achieve a tension-free anastomosis. While data are limited comparing these two techniques in the setting of ileocolic anastomoses, smaller studies suggest that either technique is safe and leads to comparable postoperative outcomes.…”

“…In such instances, approximating the distal ileum to the remaining transverse colon can be difficult and may require additional mobilization maneuvers such as splenic flexure mobilization. 1 Once the small bowel and/or remaining colon is appropriately mobilized, ileocolic anastomoses after right hemicolectomy can be performed open or minimally invasive in an intracorporeal or extracorporeal technique. A 2020 meta-analysis comparing intracorporeal and extracorporeal anastomosis after laparoscopic right hemicolectomy demonstrated decrease postoperative complications and length of stay among patients with intracorporeal ileocolic anastomoses.…”

“…The Kono-S anastomosis is a more recently described anastomosis used specifically in the context of Crohn's disease. It was developed as a hand-sewn anastomosis using the antimesenteric sides of the intestine, which preserves the mesentery from the resected segment 1 18 ( Fig. 4 ).…”