Preprocedural Planning
Preoperative fluid resuscitation to optimize hydration status is imperative because patients who present in emergency settings are frequently dehydrated.
Preoperative antibiotic prophylaxis is a must to prevent infective complications in emergency settings, as well as in some elective settings when associated with a major surgical procedure.
A nasogastric tube and indwelling urinary catheter should be inserted to decompress the stomach and the urinary bladder, respectively. Decompression of the stomach reduces the risk of aspiration of gastric contents during induction of anesthesia.
Traditionally, mechanical bowel preparation has been given before elective colorectal procedures to prevent anastomotic complications. [10] However, there is evidence in the literature to suggest that mechanical bowel preparation does not have any beneficial effect on the complication rate; in fact, it might have a detrimental effect on healing by causing immune changes in colonic mucosa that interfere with the healing process. [11, 12]
Venous thromboembolism prophylaxis is a must to prevent deep vein thrombosis of lower limbs and possibly mesenteric venous thrombosis in high-risk patients (thrombophilic state). [13]
Equipment
Intestinal anastomosis is performed in an operating room, which should be equipped with the following:
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Anesthetic equipment, overhead lights, and an operating table that is preferably power-controlled to ensure smooth and accurate positioning for various surgical procedures, electrodiathermy, and suctioning systems
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Appropriate laparoscopic instruments and monitors (preferably high-definition) if laparoscopic resection and anastomosis are contemplated
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Double-lumen endotracheal tube with single-lung ventilation is required for thoracotomy/thoracoscopic esophagectomy and anastomosis
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All types of suture materials (absorbable/nonabsorbable, monofilament/multifilament) used for intestinal anastomosis
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Stapling devices commonly used for intestinal anastomosis, such as a transverse anastomosis (TA) stapler, a gastrointestinal anastomosis (GIA) stapler, and a circular end-to-end anastomosis (EEA) stapler (if stapled intestinal anastomosis is planned)
Patient Preparation
Anesthesia
Intestinal anastomosis is performed with the patient under general anesthesia. A double-lumen endotracheal tube with single-lung ventilation is required for thoracotomy/thoracoscopic esophagectomy and anastomosis. Patients who are anesthetized for emergency surgery (eg, for intestinal obstruction or gangrene gut) are at greater risk for aspiration of gastric contents. The risk of aspiration can be reduced by emptying the stomach before induction and by using rapid-sequence induction technique.
Positioning
Patient positioning depends on the type of surgical procedure to be performed. Most abdominal operations are performed with the patient supine and the arms abducted at right angles to the body or, sometimes, by the side of the body. Pelvic procedures are performed with the patient in the lithotomy position.
Care should be taken to avoid excessive flexion or abduction. Adequate padding of pressure points should be ensured to avoid neurologic damage and pressure injuries. Esophageal procedures (requiring thoracotomy) are performed with the patient in a lateral or semiprone position. Patient positioning also must be changed during the course of operation to facilitate performance of the surgical procedure.
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Completed small bowel anastomosis.
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Jejunal loop being prepared for antecolic gastrojejunostomy.
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Third layer of gastrojejunostomy completed with continuous polyglactin suture. There is no pouting of mucosa.
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Gastrojejunostomy completed using interrupted Lembert silk sutures.
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Intestinal atresia with dilated proximal loop and narrow distal loop.
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Two ends of the bowel after excising the atretic ends. Note the near equal lumen.
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Posterior wall of anastomosis completed.
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Anastomosis completed with closure of mesentry defect.
