This ppt describes in brief about the anatomy of bowel, types and properties of suture materials, types of bowel anastomosis, method of doing a bowel anastomosis and factors affecting integrity of anastomosis.

1. Principles of Anastamosis in
Alimentary Tract
Presenter
Dr. Kaushal Deep Singh

2. BOWEL WALL ANATOMY

3. BLOOD SUPPLY OF ALIMENTARY
CANAL

5. Prerequisites of Good Anastamosis
1) Planning of procedure:
2. Technical Principles:
a. Access & Exposure:
b. Meticulus dissection:
c. Resection of disease segment:
d. Anastamosis
a. Access & Exposure:
 Causes of inadequate exposure
• Inadequate anaesthesia & muscle relaxant,
• Poor assisstance,
• Inappropriate surgical incision,
• Incision of inadequate length,
• Poor illumination of operative field,
• Inadequate mobilisation of viscera.

6. 2. Blood Supply:
 Adequate blood supply to cut ends of gut
 Causes of inadequate blood supply
• Undue tension on suture line due to inadequate
mobilisation of viscera
• Devascularization of bowel during mobilisation or
preparation of anastamosis
• Strangulation of tissue by tightly knotted sutures
• Excessive use of diathermy coagulation in achieving
hemaostasis in cut ends of bowel
• Inappropriate use of occlussion clamp.

7. Suture Material
Definition of suture:
1. A strand of material that is used to approximate tissues or to ligate blood
vessels during the wound-healing period (Ratner et al. 2004).
Tools:
1. Needle
2. Suture material

8. Needles

9. Anatomy of a Surgical Needle

10. Needle point Geometry
Taper-Point
•Suited to soft tissue
•Dilates rather than cuts
Reverse cutting
•Very sharp
•Ideal for skin
•Cuts rather than dilates
Conventional
Cutting
•Very sharp
•Cuts rather than dilates
•Creates weakness allowing suture tearout
Taper-cutting
•Ideal in tough or calcified tissues
•Mainly used in Cardiac & Vascular
procedures.

11. Needle Shapes
Eye
Microsurgery
Dura
Eye
Fascia
Nerve
Muscle
Eye
Skin
Peritoneum
Cardiovascular
Oral
Pelvis
Urogenital tract
Nasal cavity
Nerve
Skin
Tendon
Eye (Anterior
segment)
Laparoscopy

12. A Truly, Ideal Suture Material?
Does Not Exist, BUT…
Sterile
Highly uniform tensile strength
Predictable performance
Non-capillary
Non-allergic
Easy to handle
Minimal tissue reaction
Absorbed completely
Smoothness - minimum tissue
drag
Ease of handling - Minimum
memory
Knot security
Cost effectiveness

13. Properties of Suture Material…
Properties
Physical
Tensile Strength,
Dimension, Knot-
pull strength, Knot
security, Stiffness
Handling
Knot-tie down, First
throw hold, Tissue
drag, Package
memory,
Suppleness
Biological
Tissue reaction,
Absorption,
Biocompatibility,
Tensile strength
loss
• All standards, test procedures and product specifications are set by U.S.
Pharmacopeia (U.S.P.)

14. Classifying Suture Material…
Sutures
Origin
Natural
Synthetic
Absorption
Absorbable
Nonabsorbabl
e
Fiber
construction
Multifilament
Monofilament
Source: Ratner et al. 2004

15. Biological
Advantages
• Handling & knotting
• Economy
Disadvantages
• Tissue reactions

16. Synthetic
Advantages
Non-Absorbables are inert
• Absorbables resemble natural
substances
• Absorption by hydrolysis
• Predictable absorption
• Strength
Disadvantages
• Monofilament
handling

17. Silk
Natural, non-absorbable
Vicryl
Synthetic, Absorbable
Classifying Suture Material…

18. Absorbable
Advantages
• Broken down by
body
• No foreign body
left
Disadvantages
• Consideration of
wound support time

19. Non - Absorbable
Advantages
• Permanent wound
Support
Disadvantages
• Foreign body left
• Suture removal can be costly and
inconvenient
• Sinus & Extrusion if left in place

20. Characteristics of Non-Absorbable Sutures
• Permanent
• Only used when long term support is required
• Removed when used for skin
• Tissue reaction generally low (except silk)
• True non-absorbable sutures include polyester,
polyethylene, polypropylene and steel

21. Multifilament (braided)
Suture Classification
Monofilament

22. Monofilament
Advantages
• Smooth surface
• Less tissue trauma
• No bacterial harbours
• No capillarity
Disadvantages
• Handling & knotting
• Ends/knot burial
• Stretch

23. Multifilament
Advantages
• Strength
• Soft & pliable
• Good handling
• Good knotting
Disadvantages
• Bacterial harbours
• Capillary action
• Tissue trauma

24. Classifying Suture Material…
Fiber construction
Source: Suture Technical Specifications, Demetech (http://www.demetech.us/suture-specs.php)

25. Classifying Suture Material…
Suture Types Generic Structure Classification Representative
Product/Brand
Catgut Collagen from animal
intestines
Natural, absorbable, twisted
multifilament (mono.)
Surgical Gut,
Chromic Gut
Silk Fibroin from silkworm
Bombyx mori
Natural, non-absorbable,
braid multifilament
Perma-Head,
Softsilk
Polypropylene Isotactic crystalline
stereoisomer of PP
Synthetic, non-absorbable,
monofilament
Prolene, Surgipro
Polyamide Nylon 6 and nylon 6,6 Synthetic, non-absorbable,
monofilament
Ethilon, Dermalon
Stainless steel 316L (low carbon) stainless
steel alloy
Metal, non-absorbable,
mono and multifilament
Ethisteel, Flexon
Polyglycolic acid/
Polylactic acid
90% PGA, 10% PLA Synthetic, absorbable,
braided multifilament
Vicryl, Vicryl
Rapide
Polydioxanone Polyester p-dioxanone Synthetic, absorbable,
monofilament
PDS II
Polyglycolic acid/
Polytrimethylene
carbonate
Copolymer of glycolic acid
and trimethylene carbonate
Synthetic, absorbable,
monofilament
Maxon
Source: Ratner et al. 2004

26. Properties: Tensile Strength Loss…
• The loss of tensile strength as a function of time (Ratner et al.
2004)
Source: Ratner et al. 2004

27. Properties: Absorption…
• Enzymatic and/pr hydrolytic breakdown of a strand
followed by elimination (Ratner et al. 2004)
Source: Ratner et al. 2004

28. Properties: In summary…
Suture Types Knot pull
strength
Knot
security
Handling Tissue
reactivity
In vivo strength
loss
Catgut Poor Poor (plain)
Fair
(chromic)
Fair High 7-10 days (plain),
21-28 days
(chromic)
Silk Fair Good Very good High 1 year
Polypropylene Fair Poor Poor Low Indefinite
Polyamide Fair Fair Good Low 1.5 – 2.5% /year
Stainless steel High Good Poor Low Indefinite
PGA/PLLA Good Fair -good Good Low 10 days – 4 weeks
Polydioxanone Fair -good Poor-fair Fair-good Low 10 days – 6 weeks
Source: Ratner et al. 2004
• Knot security: Force that a knot can withstand before
slipping or untying (Ratner et al. 2004)

29. Absorbable Sutures
PLAIN GUT:
Derived from the small
intestine of healthy sheep.
Loses 50% of tensile strength
by 5-7 days.
Used on mucosal surfaces.
CHROMIC GUT:
Treated with chromic acid to
delay tissue absorption time.
50% tensile strength by 10-14
days.
Used in episiotomy repairs.

30. •Polyglycolic acid (Dexon®)
• Braided
• Low-memory
• 50% tensile strength = 25 days
• Sites = subcutaneous closure skin

31. Polydioxanone (PDS®)
• Monofilament
• 50% tensile strength = 30+ days
• Sites = need for prolonged strength,

32. Polyglycan 910 (Vicryl®)
• Braided, synthetic polymer
• 50% tensile strength for 30 days
• Used: subcutaneous

33. Absorbable Sutures
VICRYL*
MONOCRYL*
Coated
VICRYL*
Coated
VICRYL* Plus
Antibacterial Suture
PDS* II
Skin
Perineum
Oral
Lacerations
Traumatology
Ligaments
Fascia
Vessel anastomo
10 days By 42 days
Wound Support
Mass Absorption Typical Uses
30 days
60 days
20 days
30 days 56 - 70 days
90 - 120 days
56 - 70 days
180 - 210 days
Ligature
General
Bowel
Orthopaedics
Ligature
General
Bowel
Ophthalmic
Mucosa
Obstetrics
Bowel
Skin& Ligature

34. Non-absorbable Sutures
Nylon (Ethilon®):
• Non-absorbable suture
• Monofilament
• Surface closures.

35. Non-absorbable Sutures
Polypropylene (Prolene®):
• Stronger than nylon and has better overall wound
security.

36. Silk
• Braided
• Before the advent of synthetic fibers, silk was the mainstay
of wound closure.
• Workable and has excellent knot security.
Disadvantages:
• High reactivity
• Infection

37. Suture Size
5..4..3..2..1..0..2/0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/0
Thick Thin
USP (United States Pharmacopoeia)
General

38. Volume % Reduction With Decreasing Size
2/0
3/0
4/0
5/0
6/0
7/0
8/0
2/0
3/0
4/0
5/0
6/0
7/0
8/0
51%
40%
49%
54%
50%
44%
51%
40%
49%
54%
50%
44%

39. Suture Selection
Bowel: 2/0 - 3/0
Fascia: 1 - 0
Skin: 2/0 - 5/0
Arteries: 2/0 - 8/0
Micro surgery 9/0 - 10/0
Corneal closure: 9/0 - 10/0

40. • Anastamosis with absorbable sutures are weaker than non-
absorbable sutures during early phase of healing.
• Single layer anastamosis-Non-absorbable suture material
• Two layer anastamosis-Inner layer –Absorbable suture
-Outer layer-Non-absorbable suture
• Non-absorbable material on mucosal aspect evoke foreign
body reaction granuloma formation-Little significance in
small & large intestine,significant in stomach.
• Theoratically monofilament non-absorbable (steel
wire,polypropylene) better than braided, but practically
most surgeons prefer braided suture.size 2-0,3-0, very fine
suture cut through.

41. c) Suture technique:
 Secure healing of anastamosis requires apposition of serosa
and inversion of cut edges of gut.
 Inverting Vs Everting technique (Ravitch et al)
 Two layer Vs one layer anastamosis
Czerny Halsted & Cashny
Most surgeons Less ishchemia & tissue necrosis and
less narrowing of intestinal lumen.
Esophagus, Colon & Rectum
Stomach,small
intestine

42.  Both are equivalent and depends on surgeon preferance and
experience
 Single layer suture technique –methods of choice in
anastamosis involving extraperitoneal rectum(Everett ad
Matheson)
d) Standard sutures:
 Standard two layer anastamosis
• Inner layer – Full thickness
• Outer layer-All layer except mucosa

43.  Single layer
I. Simple:-.Full thickness with inversion.
II. Gambee stitch:- Full thickness with
twice passage through mucosa-
Used in Heineke-mikulicz pyloroplasty.
II. Submucosal simple stitch.

44. Classification of suture pattern
• Inturrupted/continuous
• Appositional/Inverting/Everting
• Simple/Tension

45. Suture Patterns Used for
Hollow Organs

46. Inverting suture patterns
Lembert (interrupted or continuous)
interrupted continuous

47. Inverting suture patterns
Halsted (Interrupted Quilt)
1
2
3

48. Inverting suture patterns
Cushing and Connel
Cushing
Connel

49. Inverting suture patterns
Parker-Kerr

50. Appositional suture patterns
Gambee suture
serosa
muscularis
submucosa
mucosa

51. Appositional suture patterns
Vertical Mattress

52. Appositional suture patterns
Horizontal Mattress

53. THE ANASTAMOSIS
1. End to End
2. End to side
3. Side to side

54. 1. End to End:
a. Small bowel
b. Ileocolic
c. Gastroduodenal
d. colorectal

55. a. Small bowel:
• Insertion of posterior outer layer of sutures.

56. • Inner layer of suture.

57. • Insertion of anterior outer layer of sutures.

58. b. Ileocolic:
• Connection of unqual ends of bowel.

59. c. Gastroduodenal anastamosis:

60. D. Colorectal Anastomosis
Two-layer method

61. • Single layer method

62. END TO SIDE ANASTOMOSIS
• 1. Technique for closure of end of bowel

63. 2. Ileocolic anastomosis

64. 3. Esophagogastric and esophagojejunal Anastomosis

65. • Gastrojejunal Anastomosis

66. SIDE TO SIDE ANASTOMOSIS
Bypass Procedures

67. STAPLING

68. Factors affecting healing of
anastamosis
 Anastamosis dehiscence in esophagus,colon,rectum˃
stomach,duodenum, small intestine
.
A. Local factors:
1. Sepsis:
• Adverse effect on healing,
• Avoid faecal soiling,
• Anastamosis to be avoided in established
peritoneal sepsis; colostomy/ileostomy preferred,
• Sepsis causes reduced collagen synthesis
and increased collagen lysis in anastamosis.

69. 2. Mechanical state of bowel:
• Specially important in colon surgery.
• Avoid fecal loading,
• Through mechanical preparation
-Purgative & Enema
-whole gut irrigation
◦PEG
◦Saline wash with nasogastric tube
• Oral antibiotics to reduce infectivity of
colonic contents (metronidazole,rifamixin)
• Excessive use can lead to
pseudomembranous colitis.
• Preop Intravenous antibiotics
prevent postoperative sepsis.
• Prophylactic antimicrobial therapy
» Don’t prevent anastamosis dehiscence but septic
compications of dehiscence tend to become less severe (reference)
» Reduce abdominal wound infection.

70. 3. Drains:
• Types (a) Open- corrugated
Closed-suction, ADK drain
(b) Active -suction
Passive- No suction
(c) Silastic
Rubber
• To remove blood/serum/fluid after significant dissection,
• Help in detecting leak early.
• Removed once drainage <25ml/day.
• Controversy whether to put them in vicinity of anastamosis.
• Safeguard patient against anastamotic leakage by permitting development of
enterocutaneous fistula following anastamotic dehiscence occurs rather than
diffusing faecal
peritonitis.
• Peritoneal drains may actually increase incidence of anastamotic dehiscence(ref
23)

71. 4. Faecal diversion:
• Proximal bowel diversion to prevent distal anastamosis.

72. B. Systemic Factors:
• Less significant
• Unfavourable effect on anastamotic healing includes:
- Advance malignancy
- Malnutrition-reduced collagen synthesis.
- Excessive intraoperative blood loss
• Hypovolemia
• tissue hypoxia.

73. C. Surgeon related variables:
• Fielding et al suggested that this is most important factor in
anastamotic dehiscence.
• Failure of judgement or failure of surgical technique or both.

74. PRACTICE MAKES A
MAN PERFECT

75. thank you