Acute Care Emergency Surgery
Mansoor Khan, David Nott in Fundamentals of Frontline Surgery, 2021
Handsewn anastomosis:After placing crushing bowel clamps across the colon, the rectum, and subsequent resection, place non-crushing clamps straight across the colon and the rectum to divide them. There are three types of anastomosis that can be created: end-to-end, end-to-side, or side-to-side.To aid approximation, place 3–0 single-layer in the corners of the bowel. Make a single layer continuous 3–0 suture, beginning with the posterior row and making sure not to strangle them. Then, remove the occluding clamps to allow blood flow to return to the ends of the bowel.After the anastomosis is done, it can be tested for any leaks by placing the patient in the reverse Trendelenburg position and filling the pelvis with saline. Using a 60 mL syringe after clamping the colon proximal to the air, and, the surgeon inflates the colon with air, and the area is checked for adequate distention and the presence of bubbling.
Surgical Management of Colon Cancer
Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams in Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
As the IMA is divided centrally, the distal dissection line is just to the rectosigmoid junction or the upper rectum, at the level of the sacral promontory. The mesentery, or in the latter case of upper rectal transection, the upper mesorectum, needs to be dissected in the presacral space and then divided with the superior rectal vessels at the level of rectal division. Usually, the bowel is transected with a stapling device (e.g. 45 mm or 60 mm wide, blue or green cartridge, depending on the wall thickness). Alternatively, it can also be cut after applying bowel clamps. This dependes on the type of anastomosis. Normally a double stapling end-to-end anastomosis in then performed with a circular stapler (size 28–33). An end-to-side or side-to-end anastomosis can also be performed, but if so, it is advisable to leave only a short blind end (≤2 cm) as if left long it may cause functional problems. Alternatively, a hand-sutured anastomosis can be fashioned. In these cases, we would prefer a single-layered end-to-end anastomosis with a running suture. Normally, the mesentery does not need to be closed; however, all small bowel has to be positioned right of the mesentery in order to reduce the risk of a post-operative obstructive ileus through kinking in this area.
Wound healing angiogenesis: An overview on mathematical models
J. Belinha, R.M. Natal Jorge, J.C. Reis Campos, Mário A.P. Vaz, João Manuel, R.S. Tavares in Biodental Engineering V, 2019
In healthy tissues, mature vessels are in a quiescent state. These blood vessels are composed by a monolayer of endothelial cells surrounded by a basement membrane and coated with smooth muscle cells and pericytes, promoting endothelial cell survival and allowing vessel stability (Carmeliet 2003). However, during wound healing, quiescent vessels are exposed to proangiogenic factors and the angiogenic process is initiated. Therefore, in the region where the new blood vessel will be formed, a previously quiescent endothelial cell is converted into a tip cell. This tip cell forms filopodia, cytoplasmic elongations sensible to the growth factors gradients in the environment, which allows cell migration. The adjacent endothelial cells become stalk cells that start to proliferate and to migrate in the direction of the tip cell, resulting in vessel’s sprouting elongation. Afterwards, blood vessel density increases and the vascular sprout will fuse with another neighbouring vessel. This process is called anastomosis and allows the blood flow’s reestablishment. The unperfused vessels regress by apoptotic processes. Finally, the vasculature returns to a quiescent state, the basement membrane is restored and the new blood vessel is coated by smooth muscle cells and pericytes that stabilize it (Carmeliet, & Jain 2011). If the tissue wound healing was correctly performed, the number of vessels normalizes and returns to a level close to the one observed in uninjured tissue (Yamashita et al. 2014).
Can maneuverability in the robot assisted laparoscopic stapler during ileoileal anastomosis compensate for shorter stapler length? – A randomized experimental porcine study
Published in Scandinavian Journal of Urology, 2021
Pernille Skjold Kingo, Gitte Wrist Lam, Jørgen Bjerggaard Jensen
Re-establishment of bowel continuity is imperative when constructing urinary diversion in patients given an ileal conduit or neobladder after radical cystectomy. The risks of complications and sequelae following radical cystectomy are considerable whether you use the open or robot assisted laparoscopic approach [1,2]. Although rare, anastomotic dehiscence is one of the most serious complications [3]. However, a less recognized but most likely a more common problem is relative stenosis of the bowel anastomosis if construction of the lumen is too small. This can lead to prolonged ileus in the postoperative phase and long-term bowel problems. The construction of intestinal anastomosis has evolved remarkably over the years, from hand sewn to stapled anastomoses and from open to robotic assisted laparoscopic (RAL) technique. Nowadays, the intestinal anastomosis is performed with minimal morbidity and mortality [4]. Construction of a stapled side-to-side anastomosis allows for a faster and better anastomosis according to leak rates and a faster learning curve compared to a hand sewn end-to-end anastomosis [5–8]. Thus, side-to-side anastomosis allows for the creation of a large diameter of anastomosis. However, proper handling of the bowel and staplers with a certain length are important in order to prevent strictures of the bowel [5].
Clinical outcomes following the surgery of new autologous arteriovenous fistulas proximal to the failed ones in end-stage renal disease patients: a retrospective cohort study
Published in Renal Failure, 2019
Xianglei Kong, Lijun Tang, Liming Liang, Wei Cao, Lei Zhang, Wei Yong, Nannan Ding, Wenbin Li, Zunsong Wang, Dongmei Xu
The surgery of new AVF proximal to the failed forearm AVF was performed as an inpatient procedure under local anesthesia and consisted of either the creation of a more proximal reanastomosis of the cephalic vein to the radial artery or to the brachial artery, or the basilica vein to the brachial artery. An end-to-side anastomosis was created in the standard fashion. Technical success including: (1) improved intra-access blood flow > 20%; (2) normalized venous pressures; (3) normalized prepump pressures and return to baseline blood flow rate and (4) Abnormal duplex ultrasound return to baseline duplex ultrasound Doppler flows > 4–500 mL/min [15]. The procedure was considered anatomically successful when AVF was effectively used for HD. Successful AVF use was defined as a newly created AVF used for 30 or more continuous days for typically thrice-weekly HD [15,16].
Applications of computational fluid dynamics to congenital heart diseases: a practical review for cardiovascular professionals
Published in Expert Review of Cardiovascular Therapy, 2021
Gianluca Rigatelli, Claudio Chiastra, Giancarlo Pennati, Gabriele Dubini, Francesco Migliavacca, Marco Zuin
Migliavacca et al. [51] investigated the Norwood circulation by means of CFD analyzing the shunt pressure drop–flow relationships, varying shunt implantation angles, diameter, curvature, and input pulsatility and found, as expected, that shunt diameter was the main determinant of graft flow. The researchers found that most of the pressure drop occurred close to the proximal anastomosis, and curved grafts resulted in a lower pressure drop as compared with straight grafts, due to reduced flow-line skewness toward the lateral graft wall near the proximal anastomosis. Subsequently, the same research group compared the variants of the Norwood reconstructive surgeries with post-operative catheterization and Doppler data by carrying out a multi-scale CFD analysis [52]. The Norwood operation with a modified Blalock–Taussig shunt was compared with the right ventricle to pulmonary artery shunt modification. The model predicted that the right ventricle shunt would result in higher aortic diastolic pressure, decreased pulmonary arterial pressure, lower pulmonary to systemic flow, and higher coronary perfusion relative to the innominate artery-to-right pulmonary artery shunt. CFD by means of simulation of different diameter and length of shunt can be used to predict which configuration allows for the most favorable hemodynamic pattern [53] (Figure 5).
Related Knowledge Centers
- Arteriovenous Fistula
- Birth Defect
- Gastrointestinal Tract
- Mycology
- Stoma
- Blood Vessel
- Fistula
- Foramen Ovale
- Metarteriole
- Surgical Anastomosis