When one piece of gut is much larger than the other, an alternative to the open method of end-to-end anastomosis is to join them end-to-side. You can do this when you join the ileum to the colon after a hemicolectomy, or when one loop of small gut is much bigger than the other. Close off one end and make the anastomosis as close to this end as you can, so that there is no ''cul de sac' which might be colonized by bacteria. You can also join gut of differing diameters by joining it side-to-side.
TWO MORE ANASTOMOSES END-TO-SIDE ANASTOMOSIS INDICATIONS. Anastomosing small gut to large gut.
METHOD. Mobilize the patient's large gut for 5 or 10 cm, or more if it is very large. Apply a crushing clamp to the end, and cut it off flush. Push away the contents of the distal gut, and apply a non-crushing clamp to it (A, in Fig. 9-11).
Using a straight or curved needle, close the end of the gut with continuous atraumatic sutures working from side-to-side from one end to the other (B, and C). When you have got to the other end, pull the suture tight and remove the crushing clamps. Cut away the crushed tissue. Work back to the end where you started, this time making over and over sutures (D, and E). Tie the ends of the suture and cut them off 5 mm from the knot (F).
Cover the closed end of the gut with a layer of inverting Lembert sutures through the seromuscular coat using 2/0 silk or chromic catgut (G).
Push the contents of his large gut further down and move the non-crushing clamp 6 cm from the end (H). His small gut should have a non-crushing clamp applied 5 cm from its end. Bring it close to his large gut, and insert stay sutures through the seromuscular layers only (I). Complete the layer of interrupted seromuscular sutures (J).
Open his large gut, if possible along a taenia, so as to make a stoma equal in size to his small gut (K).
Start the inner all coats layer with a Connell inverting stitch (L). Continue this as an over-and-over suture to the other end, and use another Connell inverting stitch for that end (M). Return using an over-and-over suture for the anterior layer (N). When you reach the end close it with a third Connell inverting stitch (O). Tie the two ends of the continuous all coats suture together and leave the ends 5 mm long.
Insert a layer of interrupted inverting seromuscular Lembert sutures (P, and Q). Test the patency of the lumen[md]it should admit two fingers (R). Repair the defect in the mesentery with 2/0 catgut.
Fig. 9-11 END-TO-SIDE ANASTOMOSIS. A, to H, closing the blind end of the gut. E, to G, inverting the previous layer of sutures. H, moving the non-crushing clamp back. I, to K, the posterior Lembert layer of the anastomosis. L, and M, the posterior all- coats layer. N, and O, the anterior all-coats layer. P, and Q, the anterior Lembert layer. R, testing patency.
SIDE-TO-SIDE ANASTOMOSIS INDICATIONS. Anastomosis when the gut is of very different diameter and end to end or end to side anastomosis is difficult, as may happen if it is obstructed: (1) In the new- born when the distal gut is small, because it has never contained anything but meconium. (2) In older patients when end-to-end anastomosis is difficult because of differences in diameter. (3) When gut is difficult to mobilize because of adhesions, as sometimes when anastomosing the ileum to the colon.
METHOD. If gut has to be resected, first close the ends of both loops of the gut to be anastomosed, as for the larger end of an end-to-side anastomosis described above (A, to G, Fig. 9- 11). If there is no gut to be resected, leave the ends in continuity.
Expel as much of the contents of both loops as you can, and apply non-crushing clamps about 6 cm from the ends of each. Insert a layer of interrupted Lembert sutures through the seromuscular coats of both of them, starting with stay sutures at each end about 1 cm from the line of your proposed incision (A, in Fig. 9-12).
Incise both pieces of gut for about 3 cm, in the line of a taenia in the case of the colon (B). Starting with a Connell inverting stitch (C), use 2/0 catgut to join the posterior cut edges of the gut with an all coats continuous over-and-over suture (D). When you reach the other end make another Connell inverting stitch. Then continue the over-and-over continuous suture along the anterior layer of the anastomosis. Finally, complete it with another Connell inverting stitch (E) and tie the ends of the catgut together, leaving 5 mm cut ends.
Insert an anterior layer of 2/0 silk or catgut Lembert seromuscular sutures (F). Test the lumen of the stoma with your fingers (G) and move the gut contents over the anastomosis to check for leaks.
Fig. 9-12 A SIDE-TO-SIDE ANASTOMOSIS is useful for doing a bypass without resecting gut. A, if, as in this figure, gut has been resected, close the ends of the two pieces of gut as in the previous figure. If, as is usually the case, and you are merely doing a bypass operation, no gut has been resected, leave the ends in continuity. Hold them with stay sutures and join them with the Lembert sutures that will form the posterior layer of the anastomosis. B, open both pieces of gut. C, start the posterior all-coats layer with a Connell stitch. D, the posterior all coats layer has reached the other end, so now insert another Connell sitch. E, the third and final Connell stitch. F, insert the anterior Lembert layer. G, test the stoma for patency. Fig. 9-13 IF YOU CANNOT ANASTOMOSE GUT, for example in a typhoid perforation, bring the gangrenous segment (A) out through a separate incision (B), cut it off so as to make an ileostomy (C), and suture all coats of the patient's gut to the skin of his abdominal wall with interrupted sutures. Refer him quickly, because there will be much fluid and electrolyte loss, which you must replace. D, he may have several stomas. F, nurse him like this. E, and F, after the late Ian Hulme Moir.