Enteroenterostomy Technique

Updated: Mar 23, 2020
  • Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed)  more...
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Technique

Approach Considerations

A mid-midline incision is best suited for enteroenterostomy. Enteroenterostomy as a part of gastric bypass surgery can also be performed laparoscopically with sutures or staplers. Enteroenterostomy can be done either in a single layer or in two layers; no significant difference has been found between the two approaches.

Enteroenterostomy may take the following three forms:

  • End-to-end - The advantage with an end-to-end enterostomy is that there is only one suture line, in contrast to the two suture lines in an end-to-side anastomosis and the three suture lines in a side-to-side anastomosis; the disadvantage is that there is a luminal size disparity between the proximal dilated bowel and the distal collapsed bowel that may be difficult to manage, and the critical mesenteric angle (bare area) is more prone to anastomotic leakage
  • End-to-side
  • Side-to-side (ie, lateral) - This is used for bypass (short-circuit operation) but can be also be used after resection; the advantages are that the luminal size disparity is not a problem and that a large stoma can be created; a disadvantage is that the loop is blind
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Creation of Enteroenterostomy

Handsewn vs stapled anastomosis

Anastomosis can be handsewn or stapled (a stapled anastomosis is quicker and ensures inversion of mucosa); no significant overall difference has been found between the two. [9] A stapled anastomosis is usually performed in a side-to-side fashion [10] by using a linear cutter or gastrointestinal anastomosis (GIA) stapler; it may also be done in an end-to-side manner. An end-to-end stapled anastomosis can be performed as well (the circumference is divided into three equal segments, each of which is closed with a linear stapler or a transverse anastomosis [TA] stapler).

Suture type

Interrupted or continuous sutures may be used for enteroenterostomy. Interrupted sutures cause less ischemia and ensure better adjustment of luminal discrepancy, but they take more time, use more suture material, and require more knots. A continuous over-and-over (running) suture is hemostatic, takes less time, uses less suture material, and requires fewer knots; however, a continuous suture leads to more ischemia.

Single-layer vs two-layer anastomosis

For a single-layer (seromusculosubmucosal, extramucosal) anastomosis, bites include all layers except mucosa (submucosa must be included). The advantages include less ischemia, less compromise (narrowing) of the lumen, and avoidance of mucosal eversion (extrusion).

A two-layer anastomosis includes the following:

  • Posterior outer seromuscular (Lembert) sutures (usually interrupted but may be continuous)
  • Posterior-inner all-layer (full-thickness) through-and-through (over-and-over) continuous (for better hemostasis) suture with intermittent (after every four or five bites) locking to avoid a purse-string effect
  • Anterior-inner all-layer (Connell–full thickness, inverting, outside in and then inside out on the same bowel end with loop on mucosa) suture or through-and through continuous suture; the serosa is lifted with a fine nontoothed forceps so that mucosa falls back while the mucosa is being inverted by the assistant with a fine nontoothed forceps
  • Anterior-outer seromuscular (Lembert) sutures (usually interrupted but may be continuous)

Another option is to start in the middle of the posterior layer with a double-needle suture; one half of the posterior layer is completed with one needle and the other half with the other needle. The suture then turns around both corners and continues in both halves of the anterior layer and meets in the middle of the anterior layer. Any gaps or bleeding points require additional interrupted sutures in between.

The mesenteric gap is then closed; bites include the peritoneum only and should avoid mesenteric vessels.

End-to-end anastomosis

Noncrushing soft intestinal clamps (preferably linen-shod) are used on the two divided ends to bring them together, to prevent spill of intestinal contents, and to provide temporary hemostasis from the cut bowel ends. However, they should not include and occlude the vessels in the mesentery. Thereafter, stay sutures are taken at two (mesenteric and antimesenteric) corners, and the mesenteric angle of sorrow (the bare area between two layers of mesentery) is closed with a horizontal U (box) stitch.

Luminal disparity

Disparities in luminal diameter or circumference between the proximal dilated bowel and the distal collapsed bowel can be handled in several ways, as follows:

  • Interrupted sutures dividing each wall (posterior and anterior) into halves and then each half into further halves
  • In a continuous suture, the distance between two consecutive bites should be smaller on the narrower lumen side and greater on the wider lumen side
  • Cheatle maneuver - Longitudinal incision along the antimesenteric border on the narrow lumen to increase its circumference
  • End (of the wider lumen) to the side (of the narrower lumen) anastomosis - the end of the narrower side is closed with sutures or staples
  • Side-to-side anastomosis

Side-to-side anastomosis

Side-to-side anastomosis is done on the antimesenteric borders of the two loops; it avoids the mesentery and thus does not interfere with the blood supply.

Noncrushing soft intestinal clamps are used on the two divided ends. The anastomosis is usually done in two layers. Stay sutures are taken at two corners. Posterior outer seromuscular (Lembert) sutures (usually interrupted but may be continuous) are taken. The lumen should be opened about 5 mm from the seromuscular layer; this opening should be as close to the closed ends as possible to avoid a significant blind loop. Cautery can be used for opening the bowel (coagulating current for muscle and cutting for mucosa); contents are sucked and mopped.

The anastomosis includes the following:

  • Posterior outer seromuscular (Lembert) sutures (usually interrupted but may be continuous)
  • Posterior-inner all-layer (full-thickness) through-and-through (over and over) continuous (for better hemostasis) with intermittent (after every four or five bites) locking to avoid a purse-string effect
  • Anterior-inner all-layer (Connell–full thickness, inverting, outside in and then inside out on the same bowel end with loop on mucosa) suture or through-and-through continuous suture; the serosa is lifted with fine nontoothed forceps so that mucosa falls back while the mucosa is being inverted by the assistant with a fine nontoothed forceps.
  • Anterior-outer seromuscular (Lembert) sutures (usually interrupted but may be continuous)

Note that a drain is not required for enteroenterostomy.

Enteroenterostomy using compression anastomosis clips (CAC) has been described. [11] Endoscopic ultrasonography (EUS)-guided enteroenterostomy using a lumen-apposing metal stent (LAMS) has been described. [12]  

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