Editing Anastomosis (section)

== '''Sutured''' ==

=== '''Single layer     end to end''' ===

** Continuous
*** Two anchor sutures -       mesenteric and anti-mesenteric
*** Close the entire backwall       with a single running suture (generally Lembert sutures - see below)
**** Options for sutures -  Lembert, Cushing, seromuscular
**** Seromuscular inverts the        least, and may be useful when the lumen is small
*** Flip and close the other       side
*** Test lumen size by       invaginating the wall
** Interrupted
**** ''Use good seromuscular bites throughout and only pick up a small amount of mucosa''
**** The back wall (mesenteric side) is done with vertical mattress sutures - all full-thickness with knots inside. Mesenteric stay suture first, then work alternately around in each direction.
**** Posterior wall interrupted until get to 3 and 9 o'clock - leave these untied and clipped as stays
**** Flip anterior
**** The 3 and 9 o'clock 'corner' sutures are simple interrupted full-thickness, directed back behind the previous stays. Knots on outside. Flip the previous stays up in front of them, then tie. Then you can tie the previous stays on the inside and cut them. Leave the new stays long.
**** Complete the anterior wall with seromuscular sutures with knots outside - use bisecting method.
**** Leak test with betadine on blunt needle before tying last knot

=== '''Double layer     end to end''' ===

** Most commonly the inner      layer is continuous and outer layer interrupted
** Holding sutures on either      end (seromuscular at anti-mesenteric and mesenteric borders)
** Third seromuscular suture to      bisect the posterior wall
** Complete the posterior wall      with seromuscular sutures
** Retain the two holding      sutures long, but cut the others
** Flip the bowel
** Close the mucosal layer of      the posterior wall (from anterior) with a running suture (Chassin's says      use a double-ended suture)
** Complete anterior mucosal      layer using either Connell technique or a continuous Cushing suture
** Anterior seromuscular layer
** Inspect for leak/patency

=== '''Side to side     double layer''' -     full thickness inner layer, seromuscular outer layer; good for bypasses. ===

** Lay the two segments side to      side for 8cm with a continuous posterior seromuscular suture
** Incise the anti-mesenteric      borders for 5cm
** Inner wall left - continuous      over-and-over technique plus Connell suture for the corners.
*** Start in middle of back       wall with over-and-over technique towards left side
*** In to out on near side       corner, then out to in on far side
*** Now do the true Connell       stitch, out-to-in then in-to-out on the same side before crossing over       to the other side
*** Go about halfway then stop       and leave long
** Inner wall right - start      again on the posterior wall, coming around the corner with another      Connell, then meeting for the front wall and tying
** Outer front layer      seromuscular continuous - Lembert
**