anastomosis de colon con grapas

7/24/2019 Anastomosis de Colon Con Grapas

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ALTERNATIVE METHODTRIANGULATION

An alternative method of open anastomosis for large intestine involves the method of

triangulation using three separate staple lines. It is particularly useful in colocolostomy

anastomoses as in left-sided colectomies since it does not require rotation of the mesentery.

DETAILS OF PROCEDURE

The section of the bowel to be excised is isolated with Kocher clamps while thin straight

clamps, such as Glassman clamps, are placed transversely on the colon (Figure 1). Several

inches beyond these, noncrushing Scudder or rubber-shod clamps are applied to prevent

gross contamination. The specimen is excised between the Kocher and straight clamps. The

field is walled off with laparotomy pads and the clamps are opened. Obvious bleeding points

are controlled with fine ligatures. The two limbs of open bowel are brought in approximation

with correct mesentery-to-mesentery alignment (Figure 2). The mesenteric opening is closed

with interrupted fine silk sutures (Figure 3). Anterior and posterior traction sutures (A and B)

are placed halfway between the mesentery and antimesenteric borders. The full thickness of

bowel wall along the mesenteric border is aligned with several through-and-through traction

sutures or a row of Allis clamps (Figure 4). The TL60 is positioned transversely below the

Allises and traction sutures (Figure 5). This ensures inclusion of all bowel wall in the deep

staple line. After discharging the stapling instrument, the excess tissue is cut from above the

instrument jaws while preserving the traction sutures on either end (Figure 6).

A bisecting third traction suture (C) is placed through each stoma in a position corresponding

to the apex of the antimesenteric border (Figure 7). The open jaws of the TL60 are positioned

for the second side of the triangle using traction suture (B) to elevate the end of the posterior


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staple line within the jaws (Figure 8). After discharging the staple gun, the excess tissues

above the jaws is excised, leaving the apical traction suture (C) intact.

The procedure is then repeated using the two remaining traction sutures (C and A). This final

limb of the triangulation must transect each of the other two staple lines (Figure 9). Upon its

completion, the excess tissue is excised. The bowel is inspected for hemostasis and anybleeding points are secured with fine silk ligatures. Any residual mesenteric defect is closed

with interrupted sutures. The anastomosis is palpated for patency (Figure 10) and the bowel

on either side may be compressed to verify that no leak is present.

anastomosis de colon con grapas

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