On occasion, an enteroenterostomy may be used to bypass an obstructed segment of small intestine involved with regional ileitis, tumor, or extensive adhesions. A great difference in diameter of the intestine that enters and exits a point of obstruction may make an end-to-end anastomosis difficult. In some patients, a side-to-side anastomosis can provide relief of the obstruction with minimal risk and without sacrificing extensive segments of small intestine. In patients who have had previous small bowel resection or regional ileitis, this may be the procedure of choice rather than a radical resection leading to further nutritional problems despite the risk of subsequent malignancy in the involved area of enteritis. The enteroenterostomy is also used to reestablish the continuity of the small intestine after a variety of Roux-en-Y procedures.
The two loops selected for the enteroenterostomy are grasped with Babcock forceps, and noncrushing Scudder clamps may be applied to control bleeding and limit contamination from the obstructed intestine (see FIGURE 12 in Chapter 48). Traction sutures are placed in the antimesenteric border beyond the ends of the planned anastomosis. Several additional sutures may be placed and tied to provide stabilization of the two sides in preparation for introduction of the stapler (FIGURE 1).
With the area well walled off with sterile towels, a small stab wound is made with a number 11 knife blade in the antimesenteric border of each loop. The opening is made just large enough to freely admit the fork of the cutting linear stapler. After both forks have been introduced, the bowel walls are realigned before the stapler is fired. The knife in the instrument divides the septum, ensuring an adequate stoma between the two rows of staples (FIGURE 2).
The cutting linear stapler is removed, and the staple line is inspected for potential bleeding. Additional sutures may be required to control any bleeding points. Traction sutures are placed through the ends of both staple lines to approximate the wound edges in an everted manner while the stoma is held open (FIGURE 3). The mucosal margins may be approximated with Babcock forceps, which, along with the angle-retention sutures, ensure a complete inclusion of the bowel walls within the noncutting linear stapler. The stapler is fired, and all excess bowel beyond the staples is excised by cutting along the outside surface of the stapler (FIGURE 4). The new staple suture line is inspected for hemostasis. Several additional sutures are placed to secure the angles of the anastomosis (FIGURE 5), although some surgeons prefer to place additional sutures inverting the final external staple line. The adequacy of the stoma is determined by compressing the opposing intestinal wall between the thumb and index finger.